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The Child Health
Promotion Programme
Pregnancy and the first five years of life
The Child Health
Promotion Programme
Pregnancy and the first five years of life
Update of Standard One (incorporating Standard Two)
of the National Service Framework for Children,
Young People and Maternity Services (2004)
Foreword by Dr Sheila Shribman
An effective and
high-quality preventive
programme in
childhood is the
foundation of a healthy
society. This is as true
today as ever. For
more than 100 years
we have provided a preventive health service
that has protected and promoted the health
of children. As an experienced paediatrician
I have watched the Child Health Promotion
Programme (CHPP) change and develop over
the years as it has adapted to new knowledge,
changes in public expectations and changes in
the way in which services are delivered.
This is a critical moment in the development
of the CHPP. The advances taking place
in neuroscience and genetics – and our
understanding of how early childhood
development can be both promoted and
damaged – create an imperative for the CHPP
to begin in early pregnancy. At the same
time, the development of Sure Start children’s
centres gives us an opportunity to make more
of a difference to children – across a wider set
of outcomes – than we have been able to in
the past.
2
However, it is disappointing to hear that the
CHPP is being given a low priority in some
parts of the country. Health visiting and
paediatric colleagues have reported that it is
proving difficult to provide a universal CHPP,
and to meet the needs of vulnerable children
and families.
This update has been written for a number
of reasons.
To raise the profile of the CHPP and to highlight
its importance in addressing some of the serious
problems that we are facing as a society.
To set out how the CHPP can deliver a universal
preventive service at the same time as focusing
on vulnerable babies, children and families.
To provide more detail on the programme
that was set out in the National Service
Framework for Children, Young People and
Maternity Services (DH, 2004), and to give
clearer direction on what needs to be done –
and when.
To establish the CHPP within joint
commissioning and integrated children’s
services across general practice and
children’s centres.
This document sets out the standard for the
CHPP. The detail of how the programme is
implemented will be decided by the local
partners who commission and provide the
service. It is the beginning of a process to
strengthen the CHPP and to support local
delivery. The world will keep changing and
new evidence will emerge that may challenge
some of the content of today’s programme.
This means we need to make sure that we
have a skilled and flexible workforce, local
leadership and an infrastructure that is capable
of innovating, adapting and responding to the
changing needs of children and families. This
must include strategic monitoring, evaluation
and quality improvement by the primary care
trust and local authority.
Our success will be measured by the future
health and wellbeing of children, and how the
CHPP is seen by families – in particular, the
most disadvantaged families.
I would like to thank the many people
who have contributed to this publication,
in particular the members of the CHPP
Working Group.
Dr Sheila Shribman
National Clinical Director for Children,
Young People and Maternity Services
Department of Health
3
Contents
4
Introduction
5
The importance of the CHPP
6
What is new and different in this update of the CHPP?
8
The core requirements of the CHPP
14
The CHPP schedule
29
Infrastructure requirements
58
Annex A: Notes for commissioners
63
Annex B: Core elements of the CHPP workforce
66
References
74
Introduction
This guide is for primary care trusts (PCTs),
local authorities, practice-based commissioners
and providers of services in pregnancy and
the first years of life. It highlights the key role
that the Child Health Promotion Programme
(CHPP) plays in improving the health and
wellbeing of children, as part of an integrated
approach to supporting children and families.
This document is a first step: further work is
planned to support services to build a CHPP
that is fit for the future, and that meets the
needs of children and the aspirations of
families. The CHPP will be taken forward in
the forthcoming government Child Health
Strategy, which will have a strong focus on
prevention in the first years of life.
This publication sets out the recommended
standard for the delivery of the CHPP
and demonstrates how the programme
addresses priorities for the health and
wellbeing of children (such as Public Service
Agreement (PSA) indicators). Delivery of
the CHPP depends on services for children
and families being fully integrated, and
this guide will inform joint strategic plans
to promote child health and wellbeing
across all agencies. Partnership working
between different agencies on local service
development – increasingly through children’s
trust arrangements – will be the key to the
CHPP’s success.
The CHPP begins in early pregnancy and
ends at adulthood, and will be commissioned
as one programme covering all stages
of childhood. The focus of this update is
pregnancy and the first five years of life –
because this is where significant change has
taken place in the last few years, and where
we wish to see a strengthening of current
provision. The health of older children, in
particular during adolescence, remains a
priority: an integrated CHPP from pregnancy
to adulthood is essential. The learning from
this update will be used to strengthen the
CHPP for other age groups in the future.
We are fortunate to have a strong evidence
base for the CHPP, as set out in Health for All
Children (Hall and Elliman, 2006). This update
continues to adopt the recommendations of
Health for All Children as the underpinning
universal programme. This has been
supplemented by guidance from the National
Institute for Health and Clinical Excellence
(NICE) and a review of health-led parenting
programmes by the University of Warwick.
The evidence base is less clear for some
public health interventions (such as obesity
prevention). However, there is no doubt
about the importance of these public health
issues; therefore, we have taken a pragmatic
approach and included recommendations
that are based on expert consensus
(Cross-Government Obesity Unit 2008).
There are plenty of examples of high-quality,
evidence-based CHPP services across the
country, and many practitioners will already
be working in the ways recommended in this
update. However, given the range of people
now involved in delivering the CHPP and the
variability in standards and provision across
the country, it is important to outline what
good practice should look like rather than
making assumptions.
5
The importance of the CHPP
The CHPP is the early intervention and
prevention public health programme
that lies at the heart of our universal
service for children and families. At a
crucial stage of life, the CHPP’s universal
reach provides an invaluable opportunity
to identify families that are in need of
additional support and children who are
at risk of poor outcomes.
The CHPP offers every family a programme of
screening tests, immunisations, developmental
reviews, and information and guidance to
support parenting and healthy choices – all
services that children and families need to
receive if they are to achieve their optimum
health and wellbeing.
Effective implementation of the CHPP should
lead to:
• strong parent–child attachment and
positive parenting, resulting in better social
and emotional wellbeing among children;
• care that helps to keep children healthy
and safe;
• healthy eating and increased activity,
leading to a reduction in obesity;
• prevention of some serious and
communicable diseases;
• increased rates of initiation and
continuation of breastfeeding;
• readiness for school and improved learning;
• early recognition of growth disorders and
risk factors for obesity;
• early detection of – and action to address –
developmental delay, abnormalities and ill
health, and concerns about safety;
6
• identification of factors that could influence
health and wellbeing in families; and
• better short- and long-term outcomes for
children who are at risk of social exclusion.
Pregnancy and the first years of life are one
of the most important stages in the life cycle.
This is when the foundations of future health
and wellbeing are laid down, and is a time
when parents are particularly receptive to
learning and making changes. There is good
evidence that the outcomes for both children
and adults are strongly influenced by the
factors that operate during pregnancy and
the first years of life. We have always known
this, but new information about neurological
development and the impact of stress in
pregnancy, and further recognition of the
importance of attachment, all make early
intervention and prevention an imperative
(Center on the Developing Child, 2007).
This is particularly true for children who are
born into disadvantaged circumstances.
Providing a high-quality CHPP that is visible
and accessible to families with children is
a core health responsibility contributing
to the goals of Every Child Matters (HM
Government, 2004) and services provided in
Sure Start children’s centres (DH, 2007a). The
CHPP, led by health visitors, is increasingly
being delivered through integrated services
that bring together Sure Start children’s centre
staff, GPs, midwives, community nurses
and others. Children’s centres are a way of
delivering community-based services, and are
visible and accessible to families who might be
less inclined to access traditional services.
The CHPP will continue to make sure that
children receive appropriate referral to
specialist services, and to signpost families
to wider support. The programme will
ensure that each family receives support
that is appropriate for their needs – with the
most vulnerable families receiving intensive
interventions and co-ordinated support
packages. Working in partnership with
other agencies, the CHPP sits at the heart
of services for children and families.
In establishing the foundations of good
health, the CHPP makes a crucial contribution
to the Every Child Matters outcomes (and to
delivering the legal duties to promote these),
as well as to the National Service Framework
for Children, Young People and Maternity
Services (DH, 2004). The CHPP feeds directly
into The Children’s Plan (DCSF, 2007), which
includes strengthened support for all families
during the formative early years of children’s
lives, and helps parents to ensure that children
are ready for early years education, school
and later life.
It is important that PCTs make use of
children’s trust arrangements to work closely
with local authorities to jointly plan and
commission services to deliver the CHPP
locally. Monitoring, evaluating and improving
the quality of the CHPP will be a key aim.
The CHPP is key to delivering the 2008–11
PSAs1 for improving the health and wellbeing
of children – specifically the indicators
for breastfeeding, obesity prevention,
and improving emotional health and
wellbeing. The CHPP will have an impact
on safeguarding and promoting the welfare
of children, contributing to achieving the
‘improving children and young people’s
safety’ PSA (see page 64). By incorporating
the maternity PSA indicator, the updated
CHPP recognises the vital contribution that
maternity services make to a child’s future
health and wellbeing.
1 www.hm-treasury.gov.uk/media/5/A/
pbr_csr07_psa18.pdf and www.hm-treasury.gov.uk/
media/3/A/pbr_csr07_psa19.pdf
7
What is new and different in this
update of the CHPP?
Since the National Service Framework for
Children, Young People and Maternity
Services was published in 2004, there
have been significant changes in
parents’ expectations, in our knowledge
about neurological development, in our
knowledge about what interventions
work, and in the landscape of children’s
policy and services. At the same time,
we are facing pressing public health
priorities such as the rise in childhood
obesity, an increase in emotional and
behavioural problems among children
and young people, and the poor
outcomes experienced by children in
the most at-risk families.
The CHPP needs to adapt to this
changing environment, and it is
expected that local programmes will
provide:
• a major emphasis on parenting
support;
• the application of new information
about neurological development and
child development;
• the use of new technologies and
scientific developments;
• the inclusion of changed public health
priorities;
A major emphasis on parenting
support
• Supporting mothers and fathers to
provide sensitive and attuned parenting,
in particular during the first months and
years of life.
• an emphasis on integrated services;
and
• Supporting strong couple relationships and
stable positive relationships within families
(in accordance with The Children’s Plan
(DCSF, 2007)).
• an increased focus on vulnerable
children and families, underpinned by
a model of progressive universalism.
• Ensuring that contact with the family
routinely involves and supports fathers,
including non-resident fathers.
• Supporting the transition to parenthood,
especially for first-time mothers and
fathers.
8
PCTs and local authorities will need to develop
a joint strategy for the design and delivery of
parenting support services in their area.
The contribution that fathers make to
their children’s development, health and
wellbeing is important, but services do
not do enough to recognise or support
them. Research shows that a father’s
behaviour, beliefs and aspirations can
profoundly influence the health and
wellbeing of both mother and child in
positive and negative ways.
Maternity and child health services are
used to working mainly with mothers,
and this has an impact on their ability to
engage with fathers. Fathers should be
routinely invited to participate in child
health reviews, and should have their
needs assessed.
The application of new information
about neurological development and
child development
Rapid scientific advances are taking place
in the study of neuroscience and child
development, and in our understanding of the
effectiveness of early childhood programmes.
The CHPP reflects this new knowledge by:
• stressing the importance of attachment and
positive parenting in the first years of life in
determining future outcomes for children;
• introducing a greater focus on pregnancy;
• recognising the specific impact that
mothers and fathers have on their children,
as well as their combined influence;
• building a progressive universal programme
that responds to the different risk factors
for children’s future life chances, including
the effects of multiple parental risk factors;
• integrating guidelines from NICE on
promoting changes in the behaviours
that affect health, maternal mental health,
and antenatal and postnatal care; and
• incorporating interventions (where
emerging evidence shows that they can
help) to build resilience and improve
outcomes, such as the Family Nurse
Partnership programme.
The CHPP needs to reflect new
evidence that has emerged about
neurological development and the
importance of forming a strong child–
parent attachment in the first years
of life. It should also incorporate the
information that we have about the
adverse effect that maternal anxiety
and depression in pregnancy can have
on child development.
A child’s brain develops rapidly in the
first two years of life, and is influenced
by the emotional and physical
environment as well as by genetic
factors. Early interactions directly affect
the way the brain is wired, and early
relationships set the ‘thermostat’ for
later control of the stress response.
This all underlines the significance of
pregnancy and the first years of life, and
the need for mothers and fathers to be
supported during this time.
9
The use of new technologies and
scientific developments
These include:
• new vaccination and immunisation
programmes;
• new tests, such as newborn hearing
screening and expanding newborn
bloodspot screening programmes;
• maximising the potential of the internet,
digital TV, helplines and text messaging
services to provide parents with information
and guidance, and to offer them more
choice over how to access the CHPP, such
as the online NHS Early Years Life Check2
available on the NHS Choices website; and
• improved data collection systems and
electronic records.
The inclusion of changed public
health priorities
• To increase the proportion of mothers who
breastfeed for six to eight weeks or longer.
• To focus on the early identification and
prevention of obesity in children through
an emphasis on breastfeeding, delaying
weaning until babies are around six months
old, introducing children to healthy foods,
controlling portion size, limiting snacking
on foods that are high in fat and sugar,
and encouraging an active lifestyle.
• To take a proactive role in promoting the
social and emotional development of
children.
• To support parents to get the balance right
between encouraging play and physical
activity, and minimising the risk of injury,
as set out in Staying Safe: Action plan
(DCSF, 2008).
Obesity and being overweight represent
a profound public health challenge
that is comparable with smoking in its
significance and scale. According to the
latest UK statistics, just under 10 per
cent of under-19s are obese and 20 per
cent are overweight. Around 25 per
cent of adults are obese and 40 per cent
are overweight.
If no action is taken, by 2050 it is
suggested that 25 per cent of children
will be obese and 30 per cent will be
overweight. Children who are obese in
childhood are likely to remain obese into
adulthood.
Only 3 per cent of overweight or obese
children have parents who are not
overweight or obese: it is vital to work
with parents, taking a whole-family
approach (Cross-Government Obesity
Unit, 2008).
An emphasis on integrated services
• To build the CHPP team across general
practice and Sure Start children’s centres.
• To be led by a health visitor and delivered
by a range of practitioners across the health
service and the wider children’s workforce.
• Health practitioners supporting early years
staff in their role to promote the health of
children.
• Identifying when children and their families
need access to additional services, and
using the Common Assessment Framework
to assess their needs holistically.
• To work with and as part of developing
local children’s trusts.
2 Currently under development
10
Sure Start children’s centres are being
developed across the country. There
are now over 2,500 centres, with
plans for 3,500 by 2010 – one for
every community. Children’s centres
provide a range of integrated services,
such as health and family support,
as well as childcare and early years
education. Children’s centres offer
significant opportunities for improving
children’s health and are a key vehicle
for delivering the CHPP. Many health
services will either be located in
children’s centres or will work very
closely with them.
The National Audit Office’s impact
evaluation of Sure Start children’s centres
(NAO, 2006) found that these are more
effective when they work in partnership
with health services. For example,
centres that are successful at reaching
disadvantaged groups use outreach
and home visiting in co-operation with
health and community groups to reach
excluded families.
The team delivering the CHPP will include a
range of health professionals and children’s
practitioners within children’s centres, general
practice and the wider children’s workforce.
The responsibility for delivering the CHPP in
the first years of life should lie with health
professionals – in particular health visitors –
for the following reasons:
• The CHPP includes activities that require
clinical and public health skills and
knowledge.
• Health professionals are notified of all
pregnancies and births, and are responsible
for this registered population.
• Health professionals are trusted and
listened to by the public – especially
during pregnancy and around the time
of childbirth.
• Health professionals are able to address
primary, non-stigmatising, physical health
issues that are of concern to all pregnant
women, expectant fathers and parents of
newborn babies.
• The NHS has a skilled workforce that is
used to working with different levels of
need and in a range of settings, including
the home.
• Health visitors have the necessary skills to
co-ordinate the CHPP.
• GPs and practice nurses are ideally placed
to offer opportunistic health promotion and
to identify children and families who are in
need of support.
An increased focus on vulnerable
children and families, underpinned by
a model of progressive universalism
The CHPP is a progressive universal service, i.e.
it includes a universal service that is offered to
all families with additional services for those
with specific needs and risks. ‘The CHPP
schedule’ section (beginning on page 29)
includes both the universal service to be
offered to every family and the progressive
services for children and families with additional
needs and risks. A progressive universal CHPP
is one that offers a range of preventive and
early intervention services for different levels of
risk, need and protective factors.
11
If we are to reduce inequalities in children’s
health, wellbeing and achievement, we need
to focus on the most vulnerable children and
families, and allocate resources accordingly.
One of the CHPP’s key roles is to identify
children with high risk and with low protective
factors, and to ensure that these families
receive a personalised service. Poverty is one
of the biggest risk factors linked to poorer
health outcomes. Poorer children are less likely
to be breastfed, more likely to be exposed to
tobacco smoke, and more likely to be injured
at home and on the roads.
Inequalities in early learning and achievement
begin to become apparent in early childhood,
with a gap opening up between the abilities
of poor and prosperous children at as early
as two or three years of age. Children who
come from families with multiple risk factors
(e.g. mental illness, substance misuse, debt,
poor housing and domestic violence) are more
12
likely to experience a range of poor health
and social outcomes. These might include
developmental and behavioural problems,
mental illness, substance misuse, teenage
parenthood, low educational attainment and
offending behaviour.
In a diverse country such as England,
a one-size CHPP will not fit all. The use
of interpreters, understanding different
childcare practices, and taking services
to the homeless and to travelling
families will all be key features of local
programmes.
Moving the CHPP from
… to
Commissioning a minimum core
programme
Commissioning a universal core programme, plus programmes
and services to meet different levels of need and risk (progressive
universalism)
Variation of provision according to
local investment
Variation of provision according to need and risk
A focus on post-birth
An increased focus on pregnancy
A focus on children’s services
Greater integration and information sharing with family services –
including adult services
A focus mainly on mothers and
children
Working routinely with both mothers and fathers (whether they
are living together or not)
A programme that looks for problems,
deficits and risks
One that looks for and builds on strengths and protective factors
– as well as risks
A non-specific approach to emotional
issues
The proactive promotion of attachment and the prevention of
behavioural problems
A focus on surveillance and health
promotion
A greater focus on parenting support, as well as on surveillance
and health promotion
A focus on ‘contacts’
Health reviews using consultation skills and tools to support
behaviour change. Supplementing face-to-face contact with new
media and other channels where appropriate
A schedule that is determined by
physical developmental stages and
screening tests
A schedule that is also determined by social and emotional
developmental stages, parental receptiveness and parents’
priorities
The assessment of current needs
The assessment of future risks as well as current needs
An emphasis on professionally
identified needs
A greater focus on mothers’ and fathers’ goals and aspirations for
their children
Delivered by health practitioners
Led by health visitors, drawing on a range of practitioners, and
delivered through general practice and children’s centres
The separation of maternity and child
health services
Better integration and information sharing between maternity
services and the CHPP team, school health teams and adolescent
services, including child and adolescent mental health services
A lack of clarity about who is
responsible for the quality and
outcomes of the CHPP
Health visitors lead the delivery of the CHPP for a defined
population across a range of services and locations. The CHPP is
commissioned, monitored and evaluated locally, and overseen by
the PCT or children’s trust in partnership with general practice,
including population outcomes
Minimal supervision of staff or focus
on outcomes or quality improvement
Regular supervision, and monitoring of quality and outcomes of
teams and individual practitioners
Delivered through the primary
healthcare team
Delivered by the primary healthcare team and Sure Start
children’s centres
13
The core requirements of the CHPP
This update builds on the revised
fourth edition of Health for All Children
(Hall and Elliman, 2006), which will
assist in determining what should be
commissioned to meet government
standards. The following requirements
are intended to strengthen – and not
to replace – those set out in Health for
All Children.
Early identification of need and risk
At population level, commissioners need a
systematic, reliable and consistent process
for assessing needs. At an individual level,
families need a skilled assessment so that
the programme is personalised to their needs
and choices.
The CHPP health reviews provide the basis
for agreeing with each family how they will
access the CHPP over the next stage of their
child’s life. Any system of early identification
has to be able to:
• identify the risk factors that make some
children more likely to experience poorer
outcomes in later childhood, including
family and environmental factors;
• include protective factors as well as risks;
• be acceptable to both parents;
• promote engagement in services and
be non-stigmatising;
• be linked to effective interventions;
• capture the changes that take place in
the lives of children and families;
• include parental and child risks and
protective factors; and
• identify safeguarding risks for the child.
14
A variety of different processes have evolved
locally, and more needs to be done to provide
the service with validated tools. We will be
producing further guidance, in particular to
support the PSA maternity indicator. The aim
will be to enable and encourage earlier access
to maternity care, with women having the
opportunity by the twelfth week of pregnancy
to see a midwife or maternity healthcare
professional for a health and social care
assessment of their needs, risks and choices.
This assessment will form the starting point
for the CHPP.
Generic indicators can be used to identify
children who are at risk of poor educational
and social outcomes (for example, those
with parents with few or no qualifications,
poor employment prospects or mental health
problems). Neighbourhoods also affect
outcomes for children. Families subject to
a higher-than-average risk of experiencing
multiple problems include:
• families living in social housing;
• families with a young mother or
young father;
• families where the mother’s main
language is not English;
• families where the parents are not
co-resident; and
• families where one or both parents
grew up in care.
There is a clear relationship between the number of parent-based disadvantages and a range of adverse outcomes for children (Social Exclusion Task Force, 2007).
It is estimated that around 2 per cent of
families in Britain experience five or more
of the following disadvantages:
It can be difficult to identify risks early in
pregnancy, especially in first pregnancies, as
often little is known about the experience and
abilities of the parents, and the characteristics
of the child. Useful predictors during
pregnancy include:3
• young parenthood, which is linked to
poor socio-economic and educational
circumstances;
• educational problems – parents with few
or no qualifications, non-attendance or
learning difficulties;
• parents who are not in education,
employment or training;
• families who are living in poverty;
• families who are living in unsatisfactory
accommodation;
• parents with mental health problems;
• unstable partner relationships;
• Neither parent in the family is in work.
• intimate partner abuse;
• The family lives in poor-quality or overcrowded housing.
• parents with a history of anti-social or
offending behaviour;
• Neither parent has any educational qualifications.
• families with low social capital;
• Either parent has mental health problems.
• stress in pregnancy;
• At least one parent has a longstanding
limiting illness, disability or infirmity.
• The family has a low income.
• ambivalence about becoming a parent;
• low self-esteem or low self-reliance; and
• a history of abuse, mental illness or
alcoholism in the mother’s own family.
• The family cannot afford a number of
food and clothing items.
3 www.dcsf.gov.uk/rsgateway/DB/RRP/u015301/index.shtml
15
As well as generic social and psychological
indicators, there are specific risk and
protective factors for particular outcomes.
These include:
• an underlying medical or developmental
disorder and temperamental characteristics,
some of which may be genetic;
• low birthweight and prematurity;
• obesity in parents (a child is at greater risk
of becoming obese if one or both of their
parents is obese);
• poor attachment and cold, critical or
inconsistent care (this can result in
emotional and behavioural problems);
• smoking in pregnancy (this has multiple
short- and long-term adverse effects on
both the foetus and child, and can be a
wider indicator of a pregnant woman’s
self-esteem); and
• smoking by partners (this also has both a
direct and an indirect impact on children,
and is the most powerful influence on the
mother’s smoking habit).
16
Some of the indicators listed above are
more difficult to identify than others. Health
professionals need to be skilled at establishing
a trusting relationship with families and be
able to build a holistic view.
Protective factors
• Authoritative parenting combined with
warmth, with an affectionate bond of
attachment being built between the
child and the primary caregiver from
infancy.
• Parental involvement in learning.
• Protective health behaviours, such as
smoking cessation in pregnancy.
• Breastfeeding.
• Psychological resources, including self-esteem. Health and development reviews
The core purpose of health and development
reviews is to:
• assess family strengths, needs and risks;
• give mothers and fathers the opportunity
to discuss their concerns and aspirations;
• assess growth and development; and
• detect abnormalities.
Universal health and development reviews are
a key feature of the CHPP. This updated CHPP
keeps to the key ages set out in Standard
One of the National Service Framework, in
line with the Personal Child Health Record.
However, this guide provides greater detail
and places an increased emphasis on the
review at two to two-and-a-half years.
The following are the most appropriate
opportunities for screening tests and
developmental surveillance, for assessing
growth, for discussing social and emotional
development with parents and children, and
for linking children to early years services:
• By the twelfth week of pregnancy.
• The neonatal examination.
• The new baby review (around
14 days old).
• The baby’s six to eight week examination.
• By the time the child is one year old.
• Between two and two-and-a-half years old.
One of the CHPP’s core functions is to
recognise disability and developmental delay.
This includes a responsibility to provide
information, support, referral and notification
to others, and in particular there is a duty
to inform the local education authority if it
is suspected that a child may have special
educational needs. Practitioners carrying
out the CHPP health and development
reviews are expected to have knowledge
and understanding of child development,
and of the factors that influence health and
wellbeing. They need to be able to recognise
the range of normal development.
Growth is an important indicator of a child’s
health and wellbeing. Where parents or
health professionals have concerns, the
child’s growth should be measured and
plotted on appropriate charts. New growth
charts (based on World Health Organization
standards4 covering infants aged between two
weeks and two years) will be introduced at
the end of 2008, following a pilot programme.
Regular monitoring of growth continues
to be reviewed as new evidence emerges
and concerns regarding obesity increase.
Measuring and assessing the growth of young
children is a particularly skilled task, and needs
to be carried out by appropriately trained
practitioners. From birth to two years of age,
infants should be weighed without clothes
on modern, electronic, self-zeroing scales
that have been properly maintained and are
placed on a firm, flat surface. Length (up to
two years) and height must be measured on
suitable equipment designed for the purpose.
Competent physical examinations should be
undertaken for all newborn infants and at six
to eight weeks, and thereafter whenever there
is concern about a child’s health or wellbeing.
New guidelines on the physical examination
of babies soon after birth and again at six to
eight weeks will shortly be published by the
National Screening Committee
(http://nipe.screening.nhs.uk).
4 www.who.int/childgrowth/en
17
18
The CHPP health and development reviews
provide the opportunity to assess the
strengths and needs of individual children
and families, to plan for the next stage
of childhood and to evaluate the services
received so far. The topics covered and the
depth of each review will depend on the
experience and confidence of mothers and
fathers, as well as their choices. This will also
be subject to professional judgement.
Many children will have contact with a variety
of early years practitioners, all of whom need
to be alert to possible concerns. The Common
Assessment Framework should be used where
there are issues that might require support to
be provided by more than one agency. It is
important that professionals who are involved
in assessing the child’s and the family’s needs
work in partnership, and share relevant
information as required.
Most children do well and, when given
information, most parents are good judges of
their child’s progress and needs. Others may
need more support and guidance, and a small
minority will need intensive preventive input.
Reviews can provide an opportunity to plan a
package of support using local services (such
as those provided in a children’s centre) or for
referral to specialist services.
The following table gives examples of the
sorts of topics that might be covered during
a health and development review.
Examples of topics
Pregnancy
•Assessmentoftheoverallhealthandwellbeingofthemother
•Screeningforanyconditionsthatmayhaveanimpactonmother
or baby
•Smokingineitherparent
•Folicacidandotherdietaryorlifestyleadviceasrequired
•Breastfeeding(includingbothparents’attitudes)
•Mentalhealth
•Feelingsaboutpregnancy
•Assessmentofrisksandprotectivefactors
•Couplerelationship
•Assessmentofthefather’shealthandwellbeing
The child
•Generalphysicalhealth
•Emotional,behaviouralandsocialdevelopment
•Physicaldevelopment
•Speechandlanguagedevelopment
•Self-careskillsandindependence
•Evaluationoftheattachmentbetweenthechildanditsmother
and father
•Visionandhearing
•Immunisations
Parenting
•Emotionalwarmth/stability
•Caregiving
•Thefather’scontribution
•Ensuringsafetyandprotection
•Guidance,boundariesandstimulation
19
Examples of topics
Parenting
(continued)
•Supportingthechild’scognitivedevelopmentthroughinteraction,
talking and play
•Factorsthathaveanimpactontheparents’abilitytoparent
(problems such as mental ill health, poor housing, domestic
violence, substance misuse, low basic skills, learning difficulties,
physical health problems or experience of poor parenting as
a child)
•Theneedforparentalsupportand/oraccesstoformalparenting
programmes for both parents
•Provisionofcarethatpromotesandprotectsthehealthofthe
child, including feeding and diet, home and travel safety, and
smoking
•Provisionofcontraceptiveadvicetoavoidunplannedsecond
pregnancies
•Thebenefitsoftakingupfreeearlychildcareforthree-and
four-year-olds
Family
•Familyandsocialrelationships
•Thefamily’shealthandwellbeing
•Thewiderfamily,includingcarerssuchasgrandparents
•Housing,employmentandfinancialconsiderations
•Socialandcommunityelementsandresources,including
education
•Separatedparents,relationshipsanddomesticabuse
•Identificationofriskfactorsforhealthandwellbeing(smoking,
diet, activity level, alcohol consumption, drug taking, a family
history of mental health, etc.)
•Identificationoffamilialandculturalissuesthatinfluencelifestyle
•Accesstosupportfromextendedfamilyandfriends,andcultural
support networks (e.g. faith networks)
•Housing,safetyandcommunityresources
•Signpostingtoservicesandresources
•Referraltospecialistservicesifrequired
20
It is important to avoid a ‘tick box approach’
when undertaking a health and development
review, and it should always be undertaken
in partnership with the parents. Parents want
a process that recognises their strengths,
concerns and aspirations for their child.
Health professionals need to use consultation
skills, purposeful listening skills and guiding
questions to ensure that the goals of the
CHPP are aligned with the goals of the
parents – while not losing the focus of the
review. Promotional interviewing, motivational
interviewing and strength-based approaches
are emerging as useful methods.
Antenatal and postnatal promotional interviews
Antenatal and postnatal promotional
interviews (see the Centre for Parent
and Child Support website for further
information5) provide practitioners with a
proactive and non-stigmatising approach
to promoting the early psychosocial
development of babies and the transition
to parenthood. They provide a structured
way of working with mothers and fathers
during pregnancy and the postnatal
period, helping them to explore their
situation and to make more informed
decisions about their family’s needs.
Promotional interviews involve:
• using a respectful and flexible
approach to explore the mother
and father’s feelings, attitudes
and expectations in relation to the
pregnancy, the birth and the growing
relationship with the baby;
• listening to mothers and fathers carefully, encouraging them as necessary to find solutions for themselves;
• empowering parents to develop
effective strategies that build
resilience, facilitate infant development
and enable them to adapt to their
parenting role; and
• enabling parents to recognise and use
their own strengths and those of their
informal networks, as well as formal
services if appropriate.
Screening
‘Screening is a public health service in
which members of a defined population
– who do not necessarily perceive they
are at risk of, or are already affected by,
a disease or its complications – are asked
a question or offered a test, to identify
those individuals who are more likely
to be helped than harmed by further
tests or treatment to reduce the risk of
a disease or its complications.’
UK National Screening Committee
Screening is an integral part of the universal
CHPP. All the screening programmes in the
CHPP have met the criteria laid down by the
National Screening Committee. Screening
programmes require local implementation of
an agreed pathway, including clear guidelines
on referral to assessment and differential
diagnostic services. Data and information
systems should be capable of supporting the
pathway, delivering a fail-safe service and
performance management of the screening
programme. A nominated lead of the local
screening programme should be responsible
for access to screening, diagnosis and
appropriate management of cases. The lead
should also facilitate arrangements for quality
5 www.cpcs.org.uk
21
assurance and improvement of these services,
which is key to delivering improvements
in outcomes through an equitable and
universal service.
Childhood screening programmes are under
continual review, and this update reflects
the current evidence. Further information
on screening is provided on the National
Screening Committee website.6
• Biochemistry – hypothyroidism,
phenylketonuria, cystic fibrosis, medium
chain acyl-coA dehydrogenase deficiency.
• Haematology – haemoglobinopathies.
Six to eight weeks
Physical examination:
• cardiac;
Summary of the screening schedule
for the CHPP
• developmental dysplasia of the hips;
Antenatal
The first opportunity will be the assessment of
the mother by 12 weeks of pregnancy.
• testes (boys);
Antenatal screening for fetal conditions to be
carried out according to NICE guidelines. See
the guidelines on antenatal care from NICE7
for more information.
Newborn
Immediate physical external inspection after birth.
Newborn Hearing Screening Programme
(within four weeks if a hospital-based
programme or five weeks if communitybased).
By 72 hours
Physical examination:
• cardiac;
• all babies should have a clinical
examination for developmental dysplasia
of the hips. Those with an abnormality of
the hips on examination or a risk factor
should, in addition, have an ultrasound
examination;
• eyes;
• testes (boys);
• general examination; and
• matters of concern.
22
Five to eight days (ideally five days)
• Bloodspot screening.
• eyes;
• general examination; and
• matters of concern.
By five years
To be completed soon after school entry:
• Pre-school hearing screen – commissioners
must ensure that there is easy access for
children of all ages to audiology services
throughout childhood.
• All children should be screened for visual
impairment between four and five years of
age by an orthoptist-led service.
Immunisations
Immunisations should be offered to all children
and their parents. General practices and child
health record departments maintain a register
of children under five years, invite families for
immunisations and maintain a record of any
adverse reactions on the GP record.
Where necessary, local planning should aim to
target excluded or at-risk families (including
refugees, the homeless, travelling families,
very young mothers, those not registered
with a GP and those who are new to an
area). The current routine immunisation
6 www.nsc.nhs.uk/ch_screen/child_ind.htm
7 www.nice.org.uk/CG006
schedule, together with additional vaccines
recommended for some groups, can be found
at www.immunisation.nhs.uk.
At every contact, members of the CHPP team
should identify the immunisation status of
the child. The parents or carers should be
provided with good-quality, evidence-based
information and advice on immunisations,
including the benefits and possible adverse
reactions. Every contact should be used
to promote immunisation. In addition,
those immunising children should use the
opportunity to promote health and raise wider
health issues with parents.
Promotion of social and emotional
development
More is known today than ever about the
neurological development of infants, and
the impact of poor attachment and negative
parenting on a child’s physical, cognitive and
socio-emotional development – not only in
childhood, but also as a key determinant of
adult health.
The CHPP includes opportunities for parents
and practitioners to review a child’s social and
emotional development, for the practitioner to
provide evidence-based advice and guidance,
and for the practitioner to decide when
specialist input is needed. Practitioners need
to listen well, observe carefully, understand
when things are going wrong and be able to
deal with this sensitively.
for Parenting Practitioners will build on our
knowledge of what works best.
Core features of successful parenting
programmes include:
• practitioners establishing a relationship with
both parents based on trust and respect;
• recognising parents’ knowledge about their
own child, and adapting the CHPP to make
sure that it is in line with their goals and
aspirations for themselves and their child;
• considering the whole family and the
impact of wider family issues on the child;
• focusing on parents’ strengths;
• focusing on empowering parents –
understanding that self-efficacy is an
essential part of behavioural change;
• the ability to promote attachment, laying
the foundations for a child’s trust in the
world, and its later capacity for empathy
and responsiveness;
• involving fathers, ensuring that they are well
informed and making them feel welcome;
• monitoring the effectiveness of local services
at engaging with and supporting fathers,
including those in socially excluded groups;
• an understanding of family relationships
and the impact of becoming a parent;
• an appreciation of the factors that affect
parenting capacity and health, and an
understanding of the interplay between risk
and resilience;
Support for parenting
• recognising and addressing mental health
problems in either parent; and
One of the core functions of the CHPP is
to support parenting using evidence-based
programmes and practitioners who are trained
and supervised. The new National Academy
• ensuring that practitioners have
consultation skills and the ability to assess
risk and protective factors.
23
Keeping the family in mind
Those delivering the CHPP have always
recognised the importance of the family in
influencing outcomes for children. The CHPP
needs to look beyond the child to their family
Good practice for engaging fathers
in the CHPP
• From the beginning, promote the father’s
role as being important to his child’s
outcomes.
• Make it explicit that the CHPP is there for
the whole family – including the father
– and demonstrate this by providing
suitable seating for him as well as for the
mother. Address him directly, encourage
him to speak and make it clear that you
are listening.
• Arrange meetings, services, groups and
reviews to maximise the possibility of
fathers attending. Stress the importance
of their presence to both them and the
mother.
• Include positive images of fathers from
different ethnic groups and of different
ages in the literature that you produce
and display.
• Record fathers’ details – including those
of non-resident fathers. Most mothers
will give this information willingly, and
two in three pregnant women who are
not living with the father of their child
describe him as ‘a good friend’ or as
their partner.
• Include an assessment of the father’s
needs as well as the mother’s, as these
will have a direct impact on both the
mother and the child.
24
context, reviewing family health as a whole,
working in partnership with adult services and
building family strengths and resources (Social
Exclusion Task Force, 2007).
• Include an assessment of the father’s
health behaviours (e.g. in relation to
diet, smoking, and alcohol or drug use),
asking him directly wherever possible.
These behaviours have a direct impact
on both the mother and the child, and
specifically on the mother’s own health
behaviours.
• Signpost fathers to all of the relevant
services.
• Make sure that fathers (as well
as mothers) are in possession of
information about, for example, the
benefits of stopping smoking and
strategies for doing so. Where possible,
provide fathers with this information
directly (rather than second-hand, via
the mother) and ensure that it also
incorporates information on their role
in relation to their child.
• Offer antenatal preparation to fathers,
including at times that will be convenient
for working fathers (e.g. evenings).
This will also make it easier for working
mothers to attend.
For further information, see the
Fatherhood Institute website at
www.fatherhoodinstitute.org and Including
New Fathers (Fathers Direct, 2007).
Effective promotion of health and
behavioural change
The CHPP should be based on NICE’s public
health guidance on behavioural change at the
population, individual and community level
(NICE, 2007).
NICE recommendations for the delivery of
individual-level interventions and programmes
include selecting interventions that motivate
and support people to:
• understand the short-, medium- and
longer-term consequences of their healthrelated behaviour for themselves and
others;
• feel positive about the benefits of healthenhancing behaviours and changing their
behaviours;
• plan their changes in terms of easy steps
over time;
• recognise how their social contexts and
relationships may affect their behaviour,
and identify and plan for situations that
might undermine the changes they are
trying to make;
• plan explicit ‘if/then’ coping strategies to
prevent relapse;
• make a personal commitment to adopt
health-enhancing behaviours by setting
(and recording) goals to undertake clearly
defined behaviours, in particular contexts,
over a specified time; and
• share their behaviour change goals
with others.
Prevention of obesity
The Government’s obesity strategy (CrossGovernment Obesity Unit, 2008) sets out
a comprehensive action plan to tackle the
rise in obesity at every level – from action by
individuals to action by the Government itself.
The strategy includes guidance on preventing
obesity in pregnancy and the first years of life,
as well as obesity in adults.
The following factors will help to prevent
obesity:
• An assessment at 12 weeks of pregnancy,
and advice on healthy weight gain during
pregnancy.
• Making breastfeeding the norm for parents
– evidence shows that breastfeeding reduces the risk of excess weight in later life.
• Delaying weaning until around six months
of age, introducing children to healthy
foods and controlling portion size.
• Identifying early those children and families
who are most at risk (e.g. where either
the mother or the father is overweight or
obese, or where there is rapid weight gain
in the child).
• Encouraging an active lifestyle.
• For some families, skilled professional
guidance and support is needed. The
health professional should work in
partnership with the family – setting small
goals, using strength-based methods and
exploring family relationships and past
life experiences.
25
Promotion of breastfeeding
• Breastfeeding initiation in England and
Wales has increased from 71 per cent
in 2000 to 77 per cent in 2005.
• In 2005, 78 per cent of all mothers
began breastfeeding. But by the time
their babies were six weeks old, the
rate was only 50 per cent.
• The prevalence and duration of
breastfeeding has increased across the
UK, with the greatest increases among
older mothers, mothers from higher
socio-economic groups and mothers
with higher educational levels.
• In England in 2005, 46 per cent of
mothers were exclusively breastfeeding
at one week. At six weeks, only 22 per
cent were exclusively breastfeeding.
and supporting breastfeeding. However,
more needs to be done to increase the
initiation and continuation of breastfeeding
– especially among young, disadvantaged
mothers (Scientific Advisory Committee on
Nutrition, 2008).
The Government has introduced a new PSA
indicator for breastfeeding, and will monitor
continuation at six to eight weeks. The CHPP
can support delivery of this by:
• adopting UNICEF’s Baby Friendly Initiative8
(or similar) in all hospital and community
providers;
• raising awareness of the health benefits of
breastfeeding – as well as the risks of not
breastfeeding;
• raising the topic of breastfeeding whenever
possible during antenatal consultations;
• Young women in low-income areas with lower educational levels are least likely to initiate and continue breastfeeding.
• developing the skills of health professionals
so that they are able to support mothers;
• Many young mothers lack access to
key sources of advice and information
– such as antenatal classes, peer
support programmes, friends, family
and other support networks.
• providing peer support – especially during
the early weeks – to establish and continue
breastfeeding;
Breastfeeding is a priority for improving
children’s health: research continues to
emphasise the importance of breast milk as
the best nourishment for babies aged up to six
months. Breastfeeding can play an important
role in reducing health inequalities.
• making sure that there is easy access to
professional advice at times of need;
• routinely informing fathers about the
health benefits of breastfeeding, giving
them advice and encouraging them to
be supportive about breastfeeding – the
father’s involvement is a key predictor of
breastfeeding initiation and maintenance;
• using children’s centres to make antenatal
and postnatal services more accessible to
hard-to-reach groups;
There are many examples of successful local
breastfeeding initiatives, and of voluntary
organisations and community groups
playing an important role in promoting
8 www.babyfriendly.org.uk
26
• increasing awareness of breastfeeding
among young and low-income mothers by
discussing breastfeeding during pregnancy
and providing support to tackle the
barriers;
• raising the profile of the Healthy Start
initiative, whereby mothers receive advice
on healthy eating and breastfeeding; and
• avoiding the use of inappropriate
commercially sponsored promotional
material.
Additional preventive programmes
for children and families
In addition to the core universal programme,
the CHPP schedule includes a number of
evidence-based preventive interventions,
programmes and services that make up a
progressive universal service. It will be for
local children’s commissioners (working with
local parenting commissioners) to determine
which of the progressive services are offered
locally – and by whom.
The progressive services have been selected
following a systematic review (by the
University of Warwick) of health-led parenting
interventions during pregnancy and the first
three years of life.
The Commissoners’ Toolkit9 that is currently
being developed and maintained by the
National Academy for Parenting Practitioners
will help commissioners of parenting
interventions to choose programmes based on
information about their degree of success with
different groups of parents.
The additional support needed by some
parents will depend on their individual risks,
needs and choices. For the ‘middle range’ of
need, the additional support may consist of
access to groups, access to practical support
or a small number of additional contacts with
one of a number of primary care or children’s
practitioners.
The University of Warwick’s review of
the evidence highlighted the partnership
between practitioners and parents as being
key to delivering the CHPP effectively. If this
partnership is in place, the practitioner can
take advantage of other effective techniques
for promoting sensitive parenting, maintaining
infant health or supporting health promotion
more generally.
In addition, the University of Warwick review
provides evidence for:
• an assessment of need that explores
with the parents their views and feelings
about their current situation, with the
practitioner listening in a respectful and
non-judgemental manner;
• supporting both parents to develop
problem-solving strategies that enable
them to address any issues that they have
identified;
• empowering approaches in which mothers
and fathers recognise and use their
strengths, developing effective strategies
that build resilience; and
• enabling families to identify informal
networks of support to develop their
self-efficacy.
9 www.parentingacademy.org/nappcontent.
aspx?page=commstoolkit
27
This way of working with parents underpins
a number of evidence-based services in the
middle range of need and risk, such as the
Family Partnership Model,10 the Solihull
Approach11 and promotional interviewing –
as well as intensive programmes such as the
Family Nurse Partnership programme.
Families with higher levels of risk
or need
Evidence from experimental studies of
early childhood programmes suggests that
intensive structured programmes delivered
by skilled nurses (such as health visitors) can
improve the outcomes of the most at-risk
children and families. These programmes
can also produce significant cost benefits –
especially when supported by high-quality
early education, access to universal healthcare
and reductions in poverty (Center on the
Developing Child, 2007).
One of the most promising such programmes
is the Family Nurse Partnership programme
(Olds, 2006), which is being tested in
England. This is a nurse-led, intensive homevisiting preventive programme for the
most at-risk young, first-time parents. The
programme begins in early pregnancy and
continues until the child is two years old. It
recognises the importance of pregnancy and
the first years of life in influencing children’s
life chances, and is offered to first-time at-risk
parents. The programme capitalises on the
receptiveness of parents in early pregnancy
and on their willingness at this stage to
protect and do the best for their child.
The Family Nurse Partnership programme has
achieved impressive results in the US, where
it has been developed over 30 years, backed
up by a rigorous programme of research.
It is too early to assess what the impact of
the programme will be in this country, but
early learning looks promising. As well as
helping the most vulnerable, the Family Nurse
Partnership principles and methods have
wider application for universal services.
10 www.cpcs.org.uk
11 www.solihull.nhs.uk/solihullapproach/
28
The CHPP schedule
The following schedule sets out both
the core universal programme to be
commissioned and provided for all
families, and additional preventive
elements that the evidence suggests
may improve outcomes for children
with medium- and high-risk factors. The
detailed content of the programme will
always be ‘work in progress’, as research
and social changes continue to suggest
new priorities for the CHPP.
The intensity of preventive intervention will
depend on assessment at family level. The
purpose is to promote the health and wellbeing
of children – from pre-birth through to
adulthood – using a co-ordinated programme
of evidence-based prevention and early
intervention. Family circumstances may change
over time, risks will impact differently, and
categories need to be flexible in the real world.
Professional assessment of risk and protective
factors will underpin decision making.
Commissioners and practitioners will want
to offer services that are proven to make
a difference and to be cost-effective. The
services, programmes and interventions
listed in the ‘Progressive’ sections below
are based on the review carried out by the
University of Warwick. They represent the
range of ‘best buy’, evidence-based services
that commissioners will wish to consider
when making decisions about the range
of services to be offered to families with
young children. The services will be provided
in a range of settings and increasingly in
Sure Start children’s centres, as well as in
general practice.
Commissioners should endeavour to
commission evidence-based programmes
and to consider the following when making
decisions:
• Is the programme well defined?
• Who is it for? Does it have a clear
target group?
• Is it based on a well-tested theory, e.g.
attachment theory, social learning theory?
• Is there a manual to ensure that it is
delivered consistently?
• Is it explicit what parents will get, i.e. more
than support?
• What are the workforce requirements that
are needed to deliver the programme, i.e.
training, competences and supervision?
29
CHPP – an overview
Universal
•Healthanddevelopment
reviews
•Screeningandphysical
examinations
•Immunisations
•Promotionofhealthand
wellbeing, e.g.:
– smoking
– diet and physical activity
– breastfeeding and healthy
weaning
– keeping safe
– prevention of sudden infant death
– maintaining infant
health
– dental health
•Promotionofsensitive
parenting and child
development
•Involvementoffathers
•Mentalhealthneeds
assessed
•Preparationandsupport
with transition to
parenthood and family
relationships
•Signpostingtoinformation
and services
Progressive
•Emotionaland
psychological problems
addressed
•Promotionand
extra support with
breastfeeding
•Supportwithbehaviour
change (smoking, diet,
keeping safe, SIDS,
dental health)
•Parentingsupport
programmes, including
assessment and
promotion of parent–
baby interaction
•Promotingchild
development, including
language
•Additionalsupport
and monitoring for
infants with health or
developmental problems
Higher risk
•High-intensity-based
intervention
•Intensivestructured
home visiting
programmes by skilled
practitioners
•Referralforspecialist
input
•Actiontosafeguardthe
child
•Contributetocare
package led by specialist
service
•CommonAssessment
Framework completed
•Topic-basedgroupsand
learning opportunities
•Helpwithaccessingother
services and sources of
information and advice
Be alert to risk factors and signs and symptoms of child abuse, and follow local
safeguarding procedures where there is cause for concern
30
Pregnancy
UP TO
Universal
WEEKS
28
Promotion of health and wellbeing
Preparation for parenthood
• A full health and social care assessment
of needs, risks and choices by 12 weeks
of pregnancy by a midwife or maternity
healthcare professional.
To begin early in pregnancy and to include:
• Notification to the CHPP team of prospective
parents requiring additional early intervention
and prevention (see page 15).
• Routine antenatal care and screening for
maternal infections, rubella susceptibility,
blood disorders and fetal anomalies. Health
and lifestyle advice to include diet, weight
control, physical activity, smoking, stress
in pregnancy, alcohol, drug intake, etc.
See NICE guidance on antenatal care CG 6
(National Collaborating Centre for Women’s
and Children’s Health, 2003).
• Distribution of The Pregnancy Book12 to
first-time parents; access to written/online
information about, and preparation for,
childbirth and parenting; distribution of
antenatal screening leaflet.
• Discussion on benefits of breastfeeding
with prospective parents – and risks of not
breastfeeding.
• Introduction to resources, including Sure
Start children’s centres, Family Information
Services, primary healthcare teams, and
benefits and housing advice.
• information on services and choices,
maternal/paternal rights and benefits, use of
prescription drugs during pregnancy, dietary
considerations, travel safety, maternal
self-care, etc.; and
• social support using group-based antenatal
classes in community or healthcare settings
that respond to the priorities of parents and
cover:
– the transition to parenthood (particularly
for first-time parents); relationship
issues and preparation for new roles
and responsibilities; the parent–infant
relationship; problem-solving skills (based
on programmes such as Preparation for
Parenting, First Steps in Parenting, One
Plus One13);
– the specific concerns of fathers, including
advice about supporting their partner
during pregnancy and labour, care
of infants, emotional and practical
preparation for fatherhood (particularly
for first-time fathers);
– discussion on breastfeeding using interactive group work and/or peer support programmes; and
– standard health promotion.
• Support for families whose first language is
not English.
12 www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_074920
13 www.oneplusone.org.uk/
31
Pregnancy
Pregnancy
UP TO
Progressive (including Universal)
WEEKS
Ambivalence about pregnancy, low
self-esteem and relationship problems
Problems should be addressed using:
• techniques to promote a trusting relationship
and develop problem-solving abilities within
the family (e.g. promotional/motivational
interviewing; the Family Partnership Model;14
and the Solihull approach15):
– establish what individual support needs
are;
– provide one or two structured listening
support contacts;
– work in partnership with families to develop problem-solving skills;
Women who smoke
Women who smoke should be offered:
• smoking cessation interventions, including
behavioural interventions combined
with social support and incentives for
achievement; and telephone counselling
(NHS helplines);
• involvement of partners, if they agree, in
the implementation of smoking-reduction/
cessation programmes; and
• additional strategies, such as planning of
smoke-free environments for children (e.g.
areas within the home that are smoke-free).
• support to access antenatal care; and
Women who are overweight or obese
• preparation for parenthood (which could
include separate sessions for fathers only).
Women who are overweight or obese should
be offered:
Women experiencing anxiety/depression
in addition to the problems above
• If no previous episode of depression or
anxiety: social support (individual or
group-based, including antenatal groups
and parenting classes); assisted self-help
(computerised cognitive behavioural therapy;
self-help material presented to a group
or individuals, by a health worker/para­
professional).
• For women with previous episodes of nonclinical symptoms of depression and anxiety:
brief (four to six weeks), non-directive
counselling delivered at home (listening
visits16) by skilled professionals, and access
to local social support; or referral for brief
psychological treatments (such as cognitive
behavioural therapy or interpersonal
therapy).
32
28
• weight control strategies to reduce risks to
both mother and baby;
• advice about healthy eating and physical
activity; and/or
• referral to weight management services.
Breastfeeding
• Discussion on infant feeding and support to
tackle practical barriers to breastfeeding.
• Discussion of benefits and drawbacks for
mother and child.
• Discussion with the prospective father.
14 www.cpcs.org.uk/
15 www.solihull.nhs.uk/solihullapproach/
16 Listening visits are defined as unstructured, client-led discussions involving the counsellor in: active listening;
reflection; providing empathic responses; encouraging
the expression of experiences and accepting the emotions
expressed; and not offering information or advice
Pregnancy
UP TO
Progressive (including Universal)
WEEKS
28
For parents at higher risk
Including at-risk first-time young mothers; parents with learning difficulties; drug/alcohol abuse;
domestic violence; serious mental illness
At-risk first-time young mothers
Alcohol abuse
• Intensive, evidence-based programmes that
start in early pregnancy, such as the Family
Nurse Partnership programme.17
• Referral of one or both parents to local
specialist services as part of a multi-agency
strategy.
• Multimodal support combining home
visiting, peer support, life skills training
and integration within social networks
recommended for pregnant adolescents.
• CHPP team to contribute to care package
led by specialist service.
Parents with learning difficulties
• Information on support available to parents
with learning disabilities, and assistance in
interpreting information and accessing other
sources of support.
• Specialist multi-agency support should
include individual and group-based antenatal
and parent education classes, and home
visiting.
• Further support designed to address the
parent’s individual needs might include
speech and language and occupational
therapy.
Drug abuse
• Referral of one or both parents to local
specialist services as part of a multi-agency
strategy.
Domestic violence
• Follow local guidelines.
• Following assessment, provision of a safe
environment in which victims of domestic
violence can discuss concerns.
• Provision of information about sources of
support for domestic violence.
• Referral to local specialist services as part of
a multi-agency strategy.
• CHPP team to contribute to care package
led by specialist service.
Serious mental illness
• Referral of one or both parents to specialist
mental health/perinatal mental health
service.
• CHPP team to contribute to care package
led by specialist service.
• CHPP team to contribute to care package led
by specialist service.
• Doula programmes (a combination of home
visiting, role modelling and community
supports) may also help to prevent attrition
and increase sensitivity of mothers who are
in recovery.
17 Currently being tested in England
33
Pregnancy
AFTER
Universal
WEEKS
Promotion of health and wellbeing
• Ongoing identification of families in need
of additional support using criteria identified
above (see page 31).
• As for pregnancy up to 28 weeks.
Preparation for parenthood
• As for pregnancy up to 28 weeks
(see page 31).
• Distribute the Parent’s Guide to Money
information pack, designed to help expectant
parents plan their family finances.18
28
Antenatal review for prospective mother
and father with CHPP team
• Focus on emotional preparation for birth,
carer–infant relationship, care of the baby,
parenting and attachment, using techniques
such as promotional interviewing (see
page 21) to:
– identify those in need of further support
during the postnatal period; and
– establish what their support needs are.
• Inform about sources of information on
infant development and parenting, the CHPP
and Healthy Start.
Involvement of fathers
• Distribute newborn screening leaflet.
• As for pregnancy up to 28 weeks
(see page 31).
• Provide information in line with Department
of Health guidance on reducing the risk of
sudden infant death syndrome (SIDS).
• Distribute and introduce Personal Child
Health Record.
Progressive (including Universal)
• As for pregnancy up to 28 weeks
(see page 32).
For parents at higher risk
• As for pregnancy up to 28 weeks
(see page 33).
18 Information on the Parent’s Guide to Money is available at
www.fsa.gov.uk
34
BIRTH TO
Birth to one week
1
WEEK
Universal
Infant feeding
Birth experiences
• Initiate as soon as possible (within one hour
of delivery) using support from healthcare
professional, or peer unless inappropriate;
24-hour rooming-in and continuing skinto-skin contact where possible. Ongoing,
consistent, sensitive, expert support about
infant positioning. Provide information about
the benefits of colostrum and timing of first
breastfeed. Support should be culturally
appropriate and should include both parents.
• Provide an opportunity for the father, as well
as the mother, to talk about pregnancy and
birth experiences, if appropriate.
• Use the Baby Friendly Initiative18 or a similar
evidence-based best practice programme to
promote breastfeeding.
• Provide information about local support
groups.
• Parents and carers who feed with formula
should be offered appropriate and tailored
advice on safe feeding.
• Provide information on vitamin supplements
and Healthy Start.
• Provide information and advice to fathers, to
encourage their support for breastfeeding.
Health promotion
• Distribution of Personal Child Health Record,
if not already done antenatally.
• Distribution of Birth to Five19 to all mothers.
Promoting sensitive parenting
• Introduce parents to the ‘social baby’,
by providing them with information about
the sensory and perceptual capabilities of
their baby using a range of media
(e.g. The Social Baby book/video (Murray
and Andrews, 2005) or Baby Express agepaced newsletters21) or validated tools
(e.g. Brazelton22 or Nursing Care Assessment
Satellite Training – NCAST23).
• Promote closeness and sensitive, attuned
parenting, by encouraging skin-to-skin care
and the use of baby carriers.
• Provide information and support to fathers,
as well as mothers, that responds to their
individual concerns and involves active
participation with, or observation of, their
baby – over several sessions, if possible.
Hearing screening
• Newborn hearing screening soon after
birth (up to four weeks if a hospital-based
programme, and five weeks if communitybased).
• Injury prevention.
Maintaining infant health
• Anticipatory, practical guidance on reality
of early days with an infant, healthy sleep
practices and bath, book, bed routine to
increase parent–infant interaction, using
a range of media (e.g. Baby Express
newsletters20).
18 www.babyfriendly.org.uk/
19 www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_074924
20 www.thechildrensfoundation.co.uk/
21 www.thechildrensfoundation.co.uk/
22 www.brazelton.co.uk/
23 www.ncast.org
35
BIRTH TO
Birth to one week
1
WEEK
Universal
SIDS
Within the first week
• Reduction of the risk of SIDS – advice about
sleeping position, smoking, co-sleeping,
room temperature and other information in
line with best evidence.24
• Administration of vitamin K in accordance
with protocol.
By 72 hours
• Comprehensive newborn physical
examination to identify any anomalies
that present in the newborn. This includes
screening of the eyes, heart and hips
(and the testes for boys), as well as a
general examination. Where a woman is
discharged from hospital before the physical
examination has taken place, fail-safe
arrangements should be in place to ensure
that the baby is examined.
• Following identification of babies with health
or developmental problems: early referral to
specialist team; advice to parents on benefits
that may be available; and invitation to join
parent groups.
Health protection – immunisation
• BCG is offered to babies who are more
likely than the general population to come
into close and prolonged contact with
someone with tuberculosis.
See www.immunisation.nhs.uk
• Hepatitis B vaccine is given to all babies of
mothers who are hepatitis B carriers or where
other household members are carriers of
hepatitis B. The first dose is given shortly
after birth.
For guidelines on postnatal care see Routine
Postnatal Care of Women and their Babies
(NICE, 2006).
• Additional support and monitoring, as
assessed by health professional.
At five to eight days (ideally five)
• Screening for hypothyroidism,
phenylketonuria, haemoglobinopathies and
cystic fibrosis.
• Screening for medium chain acyl-coA
dehydrogenase deficiency (MCADD) is
already offered in half the country and will
be universal from March 2009.
• Ongoing review and monitoring of baby’s
health, to include important health problems,
such as weight loss.
24 www.fsid.org.uk
36
BIRTH TO
Birth to one week
1
WEEK
Progressive (including Universal)
Babies with health or developmental
problems or abnormalities
• Early referral to specialist team; advice on
benefits that may be available; invitation to
join parent groups.
• Package of additional support and
monitoring as assessed by health
professional.
Problems such as conflict with partner
and lack of social support
• Techniques to promote a trusting relationship
and develop problem-solving abilities within
the family (e.g. promotional/motivational
interviewing; Family Partnership Model;25 the
Solihull approach;26 and One Plus One Brief
Encounters27) should be used to:
– establish what individual support needs
are;
– provide one or two structured listening
support visits;28 and
– work in partnership with families to develop problem-solving skills.
Promoting sensitive parenting
• Assessment of parent–baby interaction using
validated tools (e.g. NCAST).
• Sensitive, attuned parenting (by both
mothers and fathers) should be promoted,
using media-based tools (e.g. The Social
Baby book/video (Murray and Andrews,
2005) or Baby Express newsletters29) or
validated tools (e.g. Brazelton30 or NCAST31).
• Information and support to the father,
including opportunities for direct observation
and interaction with the child.
• Individualised coaching (by a skilled
professional) aimed at stimulating attuned
interactions at one day, two days and seven
days and involving both fathers and mothers
where possible.
Infant feeding and children at risk of
obesity
• Additional individual support and access to
advice, to promote exclusive breastfeeding.
• Provide information about local support
groups.
• Information on Healthy Start and vitamin
supplements.
• Information on delay in introducing solids
until six months.
Parents who smoke
• Smoking cessation interventions should
not be offered to women in the immediate
postnatal period.
• Advice should include the prevention
of exposure of infants to smoke and
the creation of smoke-free areas within
the home and cars.
SIDS
• Advice on reducing the risk of SIDS when
there are increased risks (e.g. smoking,
co-sleeping) for demographically highrisk groups (e.g. first-time mothers, single
mothers, families on low income).
25 www.cpcs.org.uk/
26 www.solihull.nhs.uk/solihullapproach/
27 www.oneplusone.org.uk/
28 Listening visits are defined as unstructured, client-led discussions involving the counsellor in: active listening;
reflection; providing empathic responses; encouraging
the expression of experiences and accepting the emotions
expressed; and not offering information or advice
29 www.thechildrensfoundation.co.uk/
30 www.brazelton.co.uk/
31 www.ncast.org
37
BIRTH TO
Birth to one week
1
WEEK
Progressive (including Universal)
For families at higher risk
Including at-risk first-time young mothers; parents with learning difficulties; drug/alcohol abuse;
domestic violence; serious mental illness
At-risk first-time young mothers
Alcohol abuse
• Intensive evidence-based programmes that
start in early pregnancy, such as the Family
Nurse Partnership programme.32
• Multimodal support combining home
visiting, peer support, life skills training and
integration within social networks.
• Referral of one or both parents to local
specialist services as part of a multi-agency
strategy.
Parents with learning difficulties
• Information on support available to parents
with learning disabilities, and assistance in
interpreting information and accessing other
sources of support.
• Specialist multi-agency support should
include individual and group-based parent
education classes, and home visiting.
• Further support designed to address the
parent’s individual needs might include
speech, language and occupational therapy.
• CHPP team to contribute to care package
led by specialist service.
Domestic violence
• Follow local guidelines.
• Following assessment, provision of a safe
environment in which victims of domestic
violence can discuss concerns.
• Provision of information about sources of
support for domestic violence.
• Referral to local specialist services as part of
a multi-agency strategy.
• CHPP team to contribute to care package
led by specialist service.
Drug abuse
Serious mental illness
• Referral of one or both parents to local
specialist services as part of a multi-agency
strategy.
• Referral of one or both parents to specialist
mental health/perinatal mental health
service.
• CHPP team to contribute to care package led
by specialist service.
• CHPP team to contribute to care package
led by specialist service.
• Doula programmes (a combination of home
visiting, role modelling and community
supports) may also help to prevent attrition
and increase sensitivity of mothers who are
in recovery.
32 Subject to testing in England
38
1–6
One to six weeks
WEEKS
Universal
New baby review by 14 days with mother
and father: face-to-face review by health
professional, to include:
Infant feeding
• Use the Baby Friendly Initiative33 or a similar
evidence-based best practice programme to
support continuation of breastfeeding.
• Individual support and access to advice to
promote exclusive breastfeeding.
• Provide information and advice to fathers to
encourage their support for breastfeeding.
• Provide information about local support
groups.
• Information on Healthy Start and vitamin
supplements.
• Information on delay in introducing solids
until six months.
• Parents and carers who feed with formula
should be offered appropriate and tailored
advice on safe feeding.
Promoting sensitive parenting
• Introduce both parents to the ‘social baby’,
by providing them with information about
the sensory and perceptual capabilities
of their baby using media-based tools
(e.g. The Social Baby book/video (Murray
and Andrews, 2005) or Baby Express
newsletters34) or validated tools (e.g.
Brazelton35 or NCAST36).
• Promote closeness and sensitive, attuned
parenting, by encouraging skin-to-skin care
and the use of soft baby carriers.
• Invitation to discuss the impact of the new
baby on partner and family relationships.
• Temperament-based anticipatory guidance37
and listening to parents’ concerns.
Examples of topics that parents may wish
to discuss include: interacting with baby
(e.g. songs and music, books); feeding,
diet and nutrition; colic; sleep; crying;
establishing a routine; safety and car seats;
the immunisation programme; prevention
of SIDS; changes in relationships; sex and
intimacy after birth; contraception; and
division of domestic chores.
• Use of media-based materials to support
sensitive parenting (e.g. Baby Express
newsletters).
• Information about the CHPP and roles of
general practice, children’s centres and other
local resources.
Promoting development
• Encouragement to use books, music and
interactive activities to promote development
and parent–baby relationship (e.g. mediabased materials such as Baby Express
newsletters and/or Bookstart38).
• Referring families whose first language is
not English to English as a second language
services.
33 www.babyfriendly.org.uk/
34 www.thechildrensfoundation.co.uk/
35 www.brazelton.co.uk/
36 www.ncast.org
37 Advice to help parents think about and understand individual infants’ temperament and use of individualised
childcare strategies, e.g. to address issues related to crying
and sleeping
38 www.bookstart.co.uk/
39
1–6
One to six weeks
WEEKS
Universal
Assessing maternal mental health
Jaundice, if prolonged
• Within 10–14 days of birth, women should
be asked appropriate and sensitive questions
to identify depression or other significant
mental health problems, such as those
recommended by the NICE guidelines on
antenatal and postnatal mental health.39
• Identification of prolonged jaundice and
referral, when indicated, according to local
protocol.
SIDS
• Reduction of the risk of SIDS – advice about
sleeping position, smoking, co-sleeping,
room temperature and other information in
line with best evidence.40
Safeguarding
• Raise awareness of accident prevention, be
alert to risk factors and signs and symptoms
of child abuse, and follow local safeguarding
procedures where there is cause for concern.
Keeping safe
• Home safety, especially the dangers of
hot water and baby bouncers.
During the first month of life
• If parents wish, or if there is professional
concern, an assessment of a child’s growth
should be carried out. This involves accurate
measurement, interpretation and explanation
of the child’s weight in relation to length, to
growth potential and to any earlier growth
measurements of the child.
• Ongoing review and monitoring of
the baby’s health, to include important
health problems, such as weight loss and
progressive jaundice.
• If hepatitis B vaccine has been given soon
after birth, the second dose is given at one
month of age.
39 Within the context of the visit, the professional should
explore possible depression. The following questions may
be helpful: ‘During the past month, have you often been
bothered by feeling down, depressed or hopeless?’ ‘During
the past month, have you often been bothered by having
little interest or pleasure in doing things?’ A third question
should be considered if the woman answers ‘yes’ to either of
the initial questions: ‘Is this something you feel you need or
want help with?’
40 www.fsid.org.uk
40
One to six weeks
1–6
Progressive (including Universal)
WEEKS
Babies with health or developmental
problems or abnormalities, including
prematurity and low birthweight
• Early referral to specialist team; advice on
benefits that may be available; invitation
to join parent groups.
• Package of additional support and
monitoring, as assessed by health
professional and drawing on the
Early Support Programme.41
for parents from demographically highrisk groups (e.g. first-time mothers, single
mothers, families on low income).
Children at risk of obesity
• Promotion of breastfeeding using the Baby
Friendly Initiative.42
• Offer of additional support to feed their
baby, including advice about the deferral
of weaning.
Infant feeding
• Advice on nutrition and exercise for the
whole family.
• Additional encouragement and support to
breastfeed exclusively.
• Invitation to group-based postnatal weight
reduction programmes.
• Peer support schemes (such as ‘Best/Breast/
Bosom Buddy’) using local, experienced
breastfeeders as volunteers; multimodal
education/social support programmes
combined with media campaigns.
• Ongoing communication with fathers
about breastfeeding and their role in
its maintenance.
Parents who smoke
• Smoking cessation interventions should
include: behavioural interventions combined
with social support and incentives for
achievement; and telephone counselling
(NHS helplines).
• Partners should be involved in the
implementation of smoking-reduction/
cessation programmes.
• Additional strategies should include planning
of smoke-free environments for children (e.g.
areas within the home that are smoke-free),
including cars.
SIDS
• Advice to both parents on reducing the
risk of SIDS when there are increased risks
(e.g. advice about smoking, co-sleeping)
Keeping safe
• Home visits, including training on healthy
sleep and correct use of basic safety
equipment, and facilitating access to
local schemes for the provision of safety
equipment. Information about thermal
injuries.
• Healthcare professionals should be alert
to risk factors and signs and symptoms of
child abuse, and should follow local child
protection procedures where there is cause
for concern.
Maintaining infant health
• Temperament-based anticipatory guidance43
– practical guidance on reality of early days
with an infant, managing crying and healthy
sleep practices, bath, book, bed routines and
activities, and encouragement of parent–
infant interaction using a range of media
(e.g. Baby Express newsletters).
41 www.earlysupport.org.uk
42 www.babyfriendly.org.uk/
43 Advice to help parents think about and understand
individual infants’ temperaments, and use of individualised
childcare strategies, e.g. to address issues related to crying
and sleeping
41
One to six weeks
1–6
Progressive (including Universal)
WEEKS
Parenting support
• Techniques to promote a trusting relationship
with both parents and to help them develop
problem-solving abilities within the family
(e.g. promotional/motivational interviewing;
Family Partnership Model;44 and the Solihull
approach45) should be used to:
– establish what individual support needs are;
– provide one or two structured listening
support visits; and
– work in partnership with families to develop problem-solving skills.
Maternal depression
• Eight listening visits46 or referral for brief
cognitive behavioural or interpersonal therapy.
• Use of dyadic therapies47 to increase
maternal sensitivity, e.g. infant massage,
interaction guidance.
• Postnatal parent–infant groups with enhanced
components for fathers. Sessions should
address and respond to the specific concerns
of fathers, including support to partner, care
of infants, and emotional issues arising from
fatherhood. Enhanced postnatal support can
include separate sessions with fathers and for
fathers only.
• Recognition and referral of women with
serious mental health problems.
Insensitive (i.e. intrusive or passive)
parenting interactions
Baby Express newsletters50) or validated tools
(e.g. Brazelton51 or NCAST52) should be used
to promote sensitive, attuned parenting.
• Invitation to group-based parenting
programmes (e.g. Mellow Parenting53 or
PIPPIN – the Parents in Partnership Parent
Infant Network) or an infant massage group.
• Father–infant groups that promote
opportunities for play and guided
observation.
Parental relationships
• Parents in conflict should be offered
access to parenting groups which address
parental conflict using specially designed
training resources (e.g. One Plus One First
Encounters54).
Promoting development
• Book sharing and invitations to groups
for songs, music and interactive activities
(e.g. PEEP55 or Bookstart56); Baby Express
newsletters.57
44 www.cpcs.org.uk
45 www.solihull.nhs.uk/solihullapproach/
46 Listening visits are defined as unstructured, client-led
discussions involving the counsellor in: active listening;
reflection; providing empathic responses; encouraging
the expression of experiences and accepting the emotions
expressed; and not offering information or advice
47 Dyadic therapies focus on both mother and baby and are
aimed at improving the mother–baby relationship
48 www.brazelton.co.uk/
49 www.ncast.org
• Assessment of parent–baby interaction using
validated tools (e.g. Brazelton48 or NCAST49).
50 www.thechildrensfoundation.co.uk/
• Media-based tools (e.g. The Social Baby
book/video (Murray and Andrews, 2005) or
53 www.mellowparenting.org/
51 www.brazelton.co.uk/
52 www.ncast.org
54 www.oneplusone.org.uk/
55 www.peep.org.uk/
56 www.bookstart.co.uk/
57 www.thechildrensfoundation.co.uk/
42
1–6
One to six weeks
WEEKS
Progressive (including Universal)
For families at higher risk
Including at-risk first-time young mothers; parents with learning difficulties; drug/alcohol abuse;
domestic violence; serious mental illness
At-risk first-time young mothers
• Intensive home visiting programmes by
skilled practitioners beginning in early
pregnancy and continuing for at least
12 months postnatally, such as the Family
Nurse Partnership programme.
• Multimodal support combining home
visiting, peer support, life skills training
and integration within social networks.
Seriously inadequate parent–infant
interaction or child protection concerns
(either parent)
• CHPP team to contribute to care package
led by specialist service.
• Doula programmes (a combination of home
visiting, role modelling and community
supports) may also help to prevent attrition
and increase sensitivity of mothers who are
in recovery.
Alcohol abuse
• Referral of one or both parents to local
specialist services as part of a multi-agency
strategy.
• Referral to specialist services.
• CHPP team to contribute to care package
led by specialist service.
• Referral to attachment-oriented or parent–
infant psychotherapy interventions.
Domestic violence
Parents with learning difficulties
• Provision of information about the support
available to parents with learning disabilities,
and assistance in interpreting information
and accessing other sources of support.
• Establishing ongoing community support
network.
• Specialist multi-agency support should
include individual and group-based antenatal
and parent education classes, and home
visiting.
• Further support designed to address the
parent’s individual needs might include
speech, language and occupational therapy.
Drug abuse
• Referral of one or both parents to local
specialist services as part of a multi-agency
strategy.
• Follow local guidelines.
• Following assessment, provision of a safe
environment in which victims of domestic
violence can discuss concerns.
• Provision of information about sources of
support for domestic violence.
• Referral to local specialist services as part of
a multi-agency strategy.
• CHPP team to contribute to care package
led by specialist service.
Serious mental illness
• Referral of either parent to specialist mental
health/perinatal mental health service.
• CHPP team to contribute to care package
led by specialist service.
43
Six weeks to six months
Universal
6 WEEKS
TO
6 MONTHS
Breastfeeding
At three to four months
• Ongoing support involving both parents.
• Supporting parenting by providing access to
parenting and child health information and
guidance (telephone helplines, websites, NHS
Direct, etc.), and information on children’s
centres and family information services.
Health review at six to eight weeks
• A comprehensive physical examination,
with emphasis on eyes, heart and hips
(and the testes for boys).
• Baby’s feeding status to be recorded –
breastfeeding, bottlefeeding or mixed feeding.
• Review of general progress and delivery of
key messages about parenting and baby’s
health, including eating and activity, weaning
and accident prevention. Information about
play and appropriate activities.
• Baby’s weight and length should be measured
and plotted, where there are concerns.
Assessing maternal mental health
• Assessment of the mother’s mental health at
six to eight weeks and three to four months,
by asking appropriate questions for the
identification of depression, such as those
recommended by the NICE guidelines on
antenatal and postnatal mental health.58
• Immunisations at three months against
diphtheria, tetanus, pertussis, polio,
Haemophilus influenzae type b and
meningococcus group C.
• Immunisations at four months against
diphtheria, tetanus, pertussis, polio,
Haemophilus influenzae type b,
pneumococcal infection and meningococcus
group C.
• If parents wish, or if there is or has been
professional concern about a child’s
growth or risk to normal growth (including
obesity), an assessment should be carried
out. This involves accurate measurement,
interpretation and explanation of the
child’s weight in relation to length, to
growth potential and to any earlier growth
measurements of the child.
At eight weeks
• Immunisation against diphtheria,
tetanus, pertussis (whooping cough),
polio, Haemophilus influenzae type b,
and pneumococcal infection. At every
immunisation, parents should have the
opportunity to raise any concerns about
caring for their baby and their health and
development, and should be provided with
information or sources of advice.
• If hepatitis B vaccine has been given after
birth, the third dose is given at eight weeks.
44
58 Within the context of the visit, the professional should
explore possible depression using the following questions:
‘During the past month, have you often been bothered
by feeling down, depressed or hopeless?’ ‘During the past
month, have you often been bothered by having little
interest or pleasure in doing things?’ A third question should
be considered if the woman answers ‘yes’ to either of the
initial questions: ‘Is this something you feel you need or
want help with?’
Six weeks to six months
Universal
6 WEEKS
TO
6 MONTHS
Maintaining infant health
• Temperament-based anticipatory guidance59
– practical guidance on managing crying
and healthy sleep practices, bath, book, bed
routines and activities, and encouragement
of parent–infant interaction using a range of
media-based interventions (e.g. Baby Express
newsletters60).
Promoting development
• Encouragement to use books, music and
interactive activities to promote development
and parent–baby relationship (e.g. mediabased materials such as Baby Express
newsletters and/or Bookstart61).
Keeping safe
• Raise awareness of accident prevention in
the home and safety in cars
• Be alert to risk factors and signs and
symptoms of child abuse.
• Follow local safeguarding procedures where
there is cause for concern.
59 Advice to help parents think about and understand
individual infants’ temperament, and use of individualised
childcare strategies, e.g. to address issues related to crying
and sleeping.
60 www.thechildrensfoundation.co.uk/
61 www.bookstart.co.uk/
45
Six
Pregnancy
weeks to six months
• Early referral to specialist team; advice on
benefits that may be available; invitation to
join parent support group.
• Package of additional support and
monitoring, as assessed by health
professional drawing on the Early
Support Programme.
Infant feeding and children at risk
of obesity
• Additional encouragement and support to
breastfeed exclusively.
• Ongoing communication with fathers
about breastfeeding and their role in
its maintenance.
• Peer support schemes (such as ‘Best/Breast/
Bosom Buddy’) using local, experienced
breastfeeders as volunteers; multimodal
education/social support programmes
combined with media campaigns.
• Promotion of Baby Friendly Initiative.62
• Offer of additional support in feeding the
baby, including advice about the deferral
of weaning.
• Advice on nutrition and physical activity for
the family.
• Partners should be involved in the
implementation of smoking-reduction/
cessation programmes.
• Additional strategies should include planning
of smoke-free environments for children (e.g.
areas within the home that are smoke-free),
including cars.
SIDS
• Reduction of the risk of SIDS – advice about
sleeping position, smoking, co-sleeping,
room temperature and other information in
line with best evidence63.
Keeping safe
• Home visits, including training on healthy
sleep and correct use of basic safety
equipment, and facilitating access to
local schemes for the provision of safety
equipment. Information about thermal
injuries.
• Healthcare professionals should be alert
to risk factors and signs and symptoms of
child abuse, and should follow local child
protection procedures where there is cause
for concern.
• Advice about reducing the risk of SIDS
where there are increased risks (e.g. sleeping
position, smoking, co-sleeping).
Parents who smoke
• Smoking cessation interventions should
include: behavioural interventions combined
with social support and incentives for
achievement; and telephone counselling
(NHS helplines).
62 www.babyfriendly.org.uk/
63 www.fsid.org.uk
46
28
6 MONTHS
TO
WEEKS
Progressive
For parents (including
at higher risk
Universal)
Babies with health or developmental
problems or abnormalities
UP TO
6 WEEKS
Six
Pregnancy
weeks to six months
• Techniques to promote a trusting relationship
and develop problem-solving abilities within
the family (e.g. promotional/motivational
interviewing; Family Partnership Model;64
and the Solihull approach65) should be
used to:
– establish what both parents’ individual
support needs are;
– provide one or two structured listening
support visits; and
– work in partnership with families to develop problem-solving skills.
Maternal depression
• Eight listening visits66 or referral for brief
cognitive behavioural or interpersonal
therapy.
• Use of dyadic therapies to increase
maternal sensitivity, e.g. infant massage,
interaction guidance.
67
• Postnatal parent–infant groups with
enhanced components for fathers. Sessions
should address and respond to the specific
concerns of fathers, including support to
partner, care of infants, and emotional issues
arising from fatherhood. Enhanced postnatal
support can include separate sessions with
fathers and for fathers only.
28
2
8
6 MONTHS
TO
WEEKS
Progressive
Universal (including
+ Progressive
Universal)
Parenting support
UP TO
TO
6 WEEKS
Insensitive (i.e. intrusive or passive)
parenting interactions
• Assessment of parent–baby interaction using
validated tools (e.g. NCAST68).
• Media-based tools (e.g. The Social Baby
book/video (Murray and Andrews, 2005) or
Baby Express newsletters69) or validated tools
(e.g. Brazelton70 or NCAST71) may be used to
promote sensitive, attuned parenting.
• Invitation to group-based parenting
programmes (e.g. Mellow Parenting72 or
PIPPIN – the Parents in Partnership Parent
Infant Network) or an infant massage group.
• Father–infant groups that promote
opportunities for play and guided observation.
Parental relationships
• Parents in conflict should be offered
access to parenting groups which address
parental conflict using specially designed
training resources (e.g. One Plus One Brief
Encounters73).
64 www.cpcs.org.uk/
65 www.solihull.nhs.uk/solihullapproach/
66 Listening visits are defined as unstructured, client-led discussions involving the counsellor in: active listening;
reflection; providing empathic responses; encouraging
the expression of experiences and accepting the emotions
expressed; and not offering information or advice
67 Dyadic therapies focus on both mother and baby and are
aimed at improving the mother–baby relationship
68 www.ncast.org
69 www.thechildrensfoundation.co.uk/
70 www.brazelton.co.uk/
71 www.ncast.org
72 www.mellowparenting.org/
73 www.oneplusone.org.uk/
47
Six
Pregnancy
weeks to six months
UP TO
6 WEEKS
28
6 MONTHS
TO
WEEKS
Progressive
For parents (including
at higher risk
Universal)
For families at higher risk
Including at risk first-time young mothers; parents with learning difficulties; drug/alcohol abuse;
domestic violence; serious mental illness
At-risk first-time young mothers
• Intensive home visiting programmes by
skilled practitioners, such as the Family Nurse
Partnership programme.
• Multimodal support combining home
visiting, peer support, life skills training and
integration within social networks.
Seriously inadequate parent–infant
interaction or child protection concerns
• Referral to specialist services.
Alcohol abuse
• Referral to local specialist services as part of
a multi-agency strategy.
• CHPP team to contribute to care package
led by specialist service.
• Referral to attachment-oriented or parent–
infant psychotherapy services.
Domestic violence
Parents with learning difficulties
• Following assessment, provision of a safe
environment in which victims of domestic
violence can discuss concerns.
• Provision of information about the support
available to parents with learning disabilities,
and assistance in interpreting information
and accessing other sources of support.
• Follow local guidelines.
• Provision of information about sources of
support for domestic violence.
• Establishing ongoing community support
networks.
• Referral to local specialist services as part of
a multi-agency strategy.
• Specialist multi-agency support should include
individual and group-based antenatal and
parent education classes, and home visiting.
• CHPP team to contribute to care package
led by specialist service.
• Further support designed to address the
parent’s individual needs might include
speech, language and occupational therapy.
Serious mental illness
Drug abuse
• Referral to local specialist services as part of a
multi-agency strategy.
• CHPP team to contribute to care package led
by specialist service.
48
• Doula programmes (a combination of home
visiting, role modelling and community
supports) may also help to prevent attrition
and increase sensitivity of mothers who are
in recovery.
• Referral to specialist mental health/perinatal
mental health service.
• CHPP team to contribute to care package
led by specialist service.
Six
Pregnancy
months to one year
Universal
Universal
• Distribution of Bookstart74 pack for babies.
Health review by one year
• Assessment of the child’s physical, emotional
and social needs in the context of their
family, including predictive risk factors.
• An opportunity for both parents to talk
about any concerns that they may have
about their baby’s health.
28
2
8
1 YEAR
TO
WEEKS
+ Progressive
Around seven to nine months
UP TO
TO
6 MONTHS
• At 12 months – immunisation against
Haemophilus influenzae type b and
meningococcus C. Immunisation history
should be checked and any missed
immunisations offered.
• At every immunisation, parents should have
the opportunity to raise any concerns about
caring for their baby and their health and
development, and should be provided with
information or sources of advice.
• Supporting parenting – provide parents with
information about attachment and the type
of developmental issues that they may now
encounter (e.g. clinginess or anxiety about
being separated from one particular parent
or carer).
Dental health
• Monitoring growth – if there is parental
or professional concern about a child’s
growth or risk to normal growth (including
obesity), an assessment should be carried
out. This involves accurate measurement,
interpretation and explanation of the
child’s weight in relation to height, to
growth potential and to any earlier growth
measurements of the child. A decision should
be made as to whether follow-up or an
intervention is appropriate, and agreement
with the family should be sought.
• From six months of age, infants should be
introduced to drinking from a cup; from one
year of age, feeding from a bottle should be
discouraged.
• Health promotion – raise awareness of dental
health and prevention, healthy eating, injury
and accident prevention relating to mobility,
safety in cars, and skin cancer prevention.
• Sugar should not be added to weaning
foods.
• As soon as teeth erupt, parents should brush
them twice daily.
• Parents should be advised to use only a
smear of toothpaste.
• The frequency and amount of sugary food
and drinks should be reduced, and, when
consumed, limited to mealtimes. Sugars
should not be consumed more than four
times a day
• Where possible, all medicines should be
sugar-free.
74 www.bookstart.co.uk/
49
Six
Pregnancy
months to one year
UP TO
6 MONTHS
28
1 YEAR
TO
WEEKS
Universal
For parents at higher risk
Maintaining infant health
Keeping safe
• Temperament-based anticipatory guidance75
– practical guidance on managing crying
and healthy sleep practices, bath, book, bed
routines and activities, and encouragement
of parent–infant interaction using a range of
media (e.g. Baby Express newsletters76).
• Advice and information on preventing
accidents and on use of safety equipment.
• Be alert to risk factors and signs and
symptoms of child abuse, and follow local
safeguarding procedures where there is cause
for concern.
Promoting development
• Book sharing and invitations to groups for
songs, music and interactive activities (e.g.
PEEP77 using the Early Learning Partnership
Model, early years librarians or Bookstart78).
• Encouragement to take up early years
education.
• Referring families whose first language is
not English to English as a second language
services.
• Supporting parents returning to work to help
their child make a smooth transition into
childcare.
75 Advice to help parents think about and understand
individual infants’ temperament and use of individualised
childcare strategies, e.g. to address issues related to crying
and sleeping
76 www.thechildrensfoundation.co.uk/
77 www.peep.org.uk/
78 www.bookstart.co.uk
50
Six
Pregnancy
months to one year
UP TO
TO
6 MONTHS
WEEKS
Progressive
Universal (including
+ Progressive
Universal)
Babies with health or developmental
problems or abnormalities
• Early referral to specialist team; advice on
benefits that may be available; invitation to
join parent groups.
• Package of additional support and
monitoring, as assessed by health
professional, and drawing on the
Early Support Programme.79
Infant feeding and children at risk
of obesity
• Advice and information to both parents on
healthy weaning, appropriate amounts and
types of food, portion size and mealtime
routines.
• Advice on nutrition and physical activity for
the family.
Parents who smoke
• Smoking cessation interventions should
include behavioural interventions combined
with social support and incentives for
achievement; and telephone counselling
(NHS helplines).
28
2
8
1 YEAR
TO
• Be alert to risk factors and signs and
symptoms of child abuse, and follow local
safeguarding procedures where there is cause
for concern.
• Advice about reducing the risk of SIDS
where there are increased risks (e.g. smoking,
co-sleeping).
Parenting support
• Health professional to facilitate access to
children’s centre and early years services.
• Techniques to promote a trusting relationship
and develop problem-solving abilities within
the family (e.g. promotional interviewing;
Family Partnership Model;80 and the Solihull
approach81) should be used to:
– establish what individual support needs
are;
– provide one or two structured listening
support visits; and
– work in partnership with families to develop problem-solving skills.
Maternal depression
• As on page 47.
• Partners should be involved in the
implementation of smoking-reduction/
cessation programmes.
Insensitive (i.e. intrusive or passive)
parenting interactions
• Additional strategies should include planning
of smoke-free environments for children
(e.g. areas within the home that are smoke-free), including cars.
Parental relationships
• As on page 47.
• As on page 47.
Keeping safe
• Provide information on correct use of basic
safety equipment and facilitate access to
local schemes for the provision of safety
equipment. Information about thermal
injuries.
79 www.earlysupport.org.uk
80 www.cpcs.org.uk/
81 www.solihull.nhs.uk/solihullapproach/
51
Six
Pregnancy
months to one year
UP TO
6 MONTHS
28
1 YEAR
TO
WEEKS
Progressive
For parents (including
at higher risk
Universal)
For families at higher risk
Keeping safe
Drug and alcohol abuse
• Be alert to risk factors and signs and
symptoms of child abuse, and follow local
safeguarding procedures where there is cause
for concern.
• Referral of one or both parents to local
specialist services as part of a multi-agency
strategy.
At-risk first-time young mothers
• Intensive home visiting programmes by
skilled practitioners, such as the Family Nurse
Partnership programme.82
• Multimodal support combining home
visiting, peer support, life skills training and
integration within social networks.
Seriously inadequate parent–infant
interaction
• Referral to attachment-oriented or parent–
infant psychotherapy interventions.
Parents with learning difficulties
• CHPP team to contribute to care package
led by specialist service.
Domestic violence
• Follow local guidelines.
• Following assessment, provision of a safe
environment in which victims of domestic
violence can discuss concerns.
• Provision of information about sources of
support for domestic violence.
• Referral to local specialist services as part of
a multi-agency strategy.
• CHPP team to contribute to care package
led by specialist service.
• Provision of information about the support
available to parents with learning disabilities,
and assistance in interpreting information
and accessing other sources of support.
Serious mental illness
• Establishing ongoing community support
networks.
• CHPP team to contribute to care package
led by specialist service.
• Referral of one or both parents to specialist
mental health/perinatal mental health
service.
• Specialist multi-agency support should
include individual and group-based
antenatal and parent education classes,
and home visiting.
• Further support designed to address the
parent’s individual needs might include
speech, language and occupational therapy.
82 Subject to testing in England
52
UP TO
TO
1–3
28
2
8
One
Pregnancy
to three years
Universal
Universal
YEARS
WEEKS
+ Progressive
At 13 months
• Immunisation against measles, mumps and
rubella (MMR) and pneumococcal infection.
At every immunisation, parents should have
the opportunity to raise any concerns about
caring for their child and their health and
development, and should be provided with
information or sources of advice.
• Immunisation history should be checked and
any missed immunisations offered.
Two- to two-and-a-half-year health review
• Review with the parents the child’s social,
emotional, behavioural and language
development, with signposting to
appropriate group-based parenting support
(e.g. the Webster-Stratton Parenting programme).
• Review development and respond to any
concerns expressed by the parents regarding
physical health, growth, development,
hearing and vision.
• Offer parents guidance on behaviour
management and an opportunity to share
concerns.
• Offer advice and information on nutrition
and physical activity for the family, and on
healthy eating, portion size and mealtime
routines.
• Raise awareness of dental care, accident
prevention, sleep management, toilet
training, sources of parenting advice.
• Offer information on family information
service, children’s centres and early years
learning provision. Refer families whose first
language is not English to English as a second
language services.
Dental health
• Sugar should not be added to foods.
• As soon as the child’s teeth erupt, parents
should brush them twice daily, using only a
smear of toothpaste.
• From the age of one year, feeding from a
bottle should be discouraged.
• The frequency and amount of sugary food
and drinks should be reduced, and, when
consumed, limited to mealtimes.
• Sugars should not be consumed more than
four times a day.
• Offer parents information on what to do if
worried about their child.
• Where possible, all medicines should be
sugar-free.
• Promote language development through
book sharing and invitations to groups for
songs, music and interactive activities (e.g.
early years librarian, PEEP83 or Bookstart84).
Keeping safe
• Provide encouragement and support to take
up early years education.
• Give health information and guidance
(telephone helplines, websites, NHS Direct).
• Review immunisation status, to catch up on
any missed immunisations.
• Advice about use of basic safety equipment
and facilitating access to local schemes
for the provision of safety equipment.
Information about thermal injuries.
• Be alert to risk factors and signs and
symptoms of child abuse, and follow local
safeguarding procedures where there is cause
for concern.
83 www.peep.org.uk/
84 www.bookstart.co.uk
53
UP TO
1–3
28
One
Pregnancy
to three years
YEARS
WEEKS
Progressive
For parents (including
at higher risk
Universal)
Children with health or developmental
problems or abnormalities
• Early referral to specialist team; advice on
benefits that may be available; invitation to
join parent groups.
• Additional support and monitoring, as
assessed by health professional, and drawing
on the Early Support Programme.85
Children at risk of obesity
• Advice and information on healthy eating,
portion size and mealtime routines.
• Advice on nutrition and physical activity for
the family.
• If there is parental or professional concern
about a child’s growth or risk to normal
growth (including obesity), an assessment
should be carried out. This may be in the
first two years of life. It involves accurate
measurement, interpretation and explanation
of the child’s weight in relation to height, to
growth potential and to any earlier growth
measurements of the child. A decision should
be made as to whether follow-up or an
intervention is appropriate, and agreement
with the family should be sought.
• Partners should be involved in the
implementation of smoking-reduction/
cessation programmes.
• Additional strategies should include planning
of smoke-free environments for children (e.g.
areas within the home that are smoke-free),
including cars.
Keeping safe
• Advice about use of basic safety equipment
and facilitating access to local schemes
for the provision of safety equipment.
Information about thermal injuries.
• Be alert to risk factors and signs and
symptoms of child abuse, and follow local
safeguarding procedures where there is cause
for concern.
Parenting support
• As on page 51.
Parents who smoke
• Smoking cessation interventions should
include behavioural interventions combined
with social support and incentives for
achievement; and telephone counselling
(NHS helplines).
85 www.earlysupport.org.uk
54
One
Pregnancy
to three years
Progressive
Universal (including
+ Progressive
Universal)
UP TO
TO
1–3
28
2
8
YEARS
WEEKS
For families at higher risk
• Be alert to risk factors and signs and
symptoms of child abuse, and follow local
safeguarding procedures where there is cause
for concern.
• Intensive programmes with skilled home
visitors, such as:
– Family Nurse Partnership for first-time
young parents until the child is two years
old; and
– Advanced Triple P Programme.86
• Maternal mental health problems/
parent–infant relationship problems:
– referral to specialist services; and/or
– parent–infant psychotherapy.
86 www.triplep.net
55
Three
Pregnancy
to five years
Universal
For parents at higher risk
At three to five years
• Support parenting – access for both parents
to Family Information Services, children’s
centres, health information and guidance
(telephone helplines, websites, NHS
Direct, etc.).
UP TO
3–5
28
YEARS
WEEKS
By five years – to be completed soon
after school entry
• Review immunisation status and offer any
missed immunisations.
• Review access to primary care and
dental care.
• Monitoring of child’s social, emotional and
behavioural development and signposting to
other services where appropriate (e.g. groupbased parenting programmes).
• Review appropriate interventions for any
physical, emotional or developmental
problems that may have been missed or
not addressed.
• Promotion of child’s development and use of
early learning centres.
• Provide children, parents and school staff
with information on specific health issues.
• Delivery (by early years services with health
professional support) of key messages about:
– promoting child health and maintaining
healthy lifestyles;
– nutrition;
– active play;
– accident prevention; and
– dental health.
• Measure height and weight for the National
Child Measurement Programme.
• Immunisation against measles, mumps and
rubella (MMR), polio and diphtheria, tetanus
and whooping cough is given between
three years four months and three years six
months. Check immunisation history and
offer any missed immunisations. At every
immunisation, parents should have the
opportunity to raise any concerns about
their child’s health and development, and
should be provided with information or
sources of advice.
• Hearing screening should be carried out
using an agreed, quality-assured protocol in
appropriate surroundings. Parental concern
about hearing should always be noted and
acted upon.
• Screen all children for visual impairment
between four and five years of age. This
should be conducted either by orthoptists
or by professionals trained and supported
by orthoptists.
• Assessment as part of the Foundation
Stage Profile.
• Be alert to risk factors and signs and
symptoms of child abuse, and follow local
safeguarding procedures where there is cause
for concern.
Progressive (including Universal)
• As under ‘One to three years’
(see page 54).
56
Infrastructure requirements
Successful delivery of the CHPP needs
to be supported by the following
systems, processes and tools. Some
are already in place and others require
local or national action.
Information for parents
Information for parents includes:
• The Pregnancy Book87 and Birth to Five,88
which provide good-quality information
for parents (in an accessible format) on the
full range of child health, development and
parenting issues;
• the Personal Child Health Record (PCHR)
(often referred to as the ’red book’), which
provides a record of a child’s health and
development, including interventions
received under the CHPP;
• screening leaflets;
• Healthy Start;
• the NHS Choices website;
• Bookstart,89 which promotes books and
reading to people of all ages and cultures. It
helps parents and carers to foster a nurturing
relationship with the child, strengthening
their emotional bond while aiding language
development and having fun;
• immunisation information resources for
parents and health professionals, available
at www.immunisation.nhs.uk;
Record keeping and data collection
systems
Connecting for Health is developing an
electronic child health record that will support
the information needs of the CHPP.
The PCHR is the main system for collecting
and recording CHPP data. At the same time,
it promotes greater personal ownership
and guardianship of the health and illness
biography of each child. The PCHR should
be the same in appearance and core content
as advised by the national PCHR group, to
ensure consistency and continuity into the
school years.
Local organisations will need to work towards
a system of information sharing across health
services by the use of one record, in which
children and families are aware of what
information is collected and who has access.
• the NHS Early Years Life Check on NHS
Choices – currently being piloted for babies
around six months; and
• locally developed information, such as
the resources developed by Families
Information Services and Sure Start
children’s centres.
58
87 www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_074920
88 www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_074924
89 www.bookstart.co.uk
Information should only be shared on a needto-know basis. Where there are concerns in
respect to safeguarding children, both parents
should be aware that the child is paramount
and that information may need to be shared
to protect the child. The development
of Contact Point, formerly known as the
Information Sharing Index, will enable
practitioners delivering services to children to
identify and contact one another more easily.
• safety and quality of the immunisation
programme;
More needs to be done to integrate maternity
and child health systems.
• delegation and accountability;
The CHPP will be delivered across a range
of settings, and where computerised data
collection systems exist, this information
should be used to inform the CHPP data
systems, to avoid duplication of records.
• continuing professional development.
Systems should be in place to collect records
into both anonymised data records for
outcome measurements and individual and
family records.
Effective inter-professional communication
systems are vital to the delivery of the CHPP.
Clinical governance
Local commissioners and providers need
to be confident that clinical governance
arrangements and professional leadership are
in place, to ensure protection of the public and
safe practice. This will include processes for:
• monitoring outcomes;
• service improvement and evaluation;
• risk management and audit of the CHPP;
• safeguarding;
• access to specialist paediatric, psychological
and other services;
• professional practice and regulation;
• assessment of competence of the
workforce;
• clinical supervision;
• confidentiality and information sharing; and
Population needs assessment and
resource allocation
The CHPP should be underpinned by a
systematic assessment of population needs
that provides a basis for configuring services
and allocating resources. That assessment
should be undertaken in partnership with
local agencies as part of joint strategic needs
assessment. The assessment will need to
identify sub-populations in the community
(e.g. teenage parents, travellers, refugees/
migrants, black and minority ethnic
communities, looked-after children, children
with disabilities) and set out action required
to address their specific needs. Lookedafter children are known to have particularly
poor health outcomes, and the CHPP needs
to take account of their specific needs.
Monitoring outcomes for sub-populations
will help to ensure that the CHPP is making
a full contribution towards addressing health
inequalities.
• safety and quality of screening
programmes;
• parent feedback;
59
Depending on local circumstances, the CHPP
will be available in a range of settings, such
as GP surgeries, children’s centres, health
centres, schools, extended schools and other
community venues. Parents need to be
able to choose how they wish to access the
service, which should be flexible and should
include the use of new technologies, such as
email and mobile phones. Services need to fit
around the requirements of working parents
and be proactive and systematic in engaging
and supporting fathers.
Data should be collated to provide the
epidemiological basis for health needs
assessment and the determination of risk
and predictive factors.
Information on uptake rates, weight and
height measurements, smoking cessation,
immunisation, breastfeeding, screening
and other measures should be used for the
strategic planning, monitoring, evaluation
and quality improvement of the CHPP.
Access to the CHPP
The CHPP needs to be highly visible,
accessible, understandable and popular with
all parents, particularly in disadvantaged
communities. Improving access to services
is a priority for achieving good outcomes
for children. More co-located and
multidisciplinary services are seen as key
objectives for providing the integrated support
that many families will need.
60
In many areas, Sure Start children’s centres are
becoming the focus for integrated children’s
services, especially for early years learning
and parenting support. It is expected that
children’s centres will provide a number of
the services listed in the ‘progressive’ part
of the schedule, for example breastfeeding
support, smoking cessation and a range of
parenting support programmes. Children’s
centres offer a way of delivering services in
a community setting that makes them more
visible and accessible to families that may
be less inclined to access traditional services.
Multi-agency teams in children’s centres have
been able to offer new and innovative services
that are designed around the needs of the
child and the family. They also have a strong
track record of community engagement and
user participation. Children’s centres may
be an ideal place from which to provide the
CHPP, making full use of the children’s centre
workforce and services and of their role in
promoting children’s health and wellbeing.
At the same time, it is important that health
visitors and other members of the team
retain good links with the primary healthcare
team. General practice delivers core aspects
of the CHPP, in particular the six to eight
week examination of all children and the
immunisation schedule. In some areas,
general practice will be the focus for delivery
of the programme. On average, a child under
school age will see their GP six times a year,
providing further opportunities to review
children’s health and support parents. New
guidelines on the physical examination of
babies soon after birth and again at six to
eight weeks will shortly be published by the
National Screening Committee.
Every general practice needs to have regular
contact with a named health visitor with
whom to discuss individual children and
families and the delivery of the CHPP.
Premises and equipment
Accommodation needs to be suitable for
clinical practice, and practitioners should
be able to access IT and record-keeping
facilities, for example growth monitoring
equipment. Whatever setting the CHPP is
delivered in, it should be appropriate for the
task, with a room suitable for clinical practice
and maintaining confidentiality, including
record storage.
Where immunisations are undertaken,
staff should be trained and competent.
Resuscitation equipment should be available
in the event of anaphylactic reactions.
Productivity and value
Offering universal services in
different ways
The CHPP is a universal service to be made
available to all. Personal contact with mothers
and fathers is important in helping to build
up a relationship. For some families, though
– especially those with a child already, for
whom outcomes are likely to be good and
who know how to access services – there are
different ways of offering services that could
free up resources for those requiring more
intensive and skilled support and guidance.
Examples include: web-based systems, such as
NHS Early Years Life Check, Netmums and the
NHS Choices website; the numerous valuable
third sector local and national parenting
support groups and organisations; and other
interactive services, funded through Parent
Know How, including Parentline Plus,90 Young
Minds91 and Contact a Family.92
Any equipment required to undertake practice
should be suitable for purpose and all safety
measures maintained. A modern, electric,
self-zeroing weighing scale, which is properly
maintained, should be used to weigh children.
It should be placed on a firm surface. Length
and height must be measured on suitable
equipment designed for the purpose.
90 www.parentlineplus.org.uk
91 www.youngminds.org.uk
92 www.cafamily.org.uk
61
Workforce flexibilities
As the core CHPP workforce, health visitors
are leading and working with teams that
include a wide range of practitioners working
across general practice and children’s centres.
Information on the CHPP workforce is
available in Annex B.
A number of options are available to improve
efficiency in the delivery of the CHPP,
including:
• administrative support, so that practitioners
can use their time effectively;
• close alignment of staff, including
co-location in general practice and
children’s centres, to share responsibility
for a defined population of children and
families;
• common systems (IT and record keeping)
of information sharing, to map children’s
health and their contacts with the service;
• systematic methods of assessing the
population and personalising services;
• developing new ways of working, new
roles and career pathways; and
• developing a CHPP team approach, to
make the best use of skills.
Outcome measures
Key indicators for the CHPP will include
PSA indicators for breastfeeding, obesity
prevention, infant mortality and the 12-week
antenatal assessment.
Additional impact measures, such as
immunisation rates, programme coverage,
smoking in pregnancy, father’s engagement,
feedback from parents, and the Foundation
Stage Profile93 at the age of five, are also
useful measures of CHPP outcomes. These
should be aggregated and used by joint
commissioners to plan, evaluate and improve
the quality of the CHPP.
Further work is being carried out to develop
child health and wellbeing indicators in
children under the age of three.
93 To be superseded by the Early Years Foundation Stage
from September 2008
62
Annex A: Notes for commissioners
This guide sets the standard for an
evidence-based prevention and early
intervention programme for children
and families, to be led by the NHS and
delivered through integrated children’s
services. It will be jointly commissioned
by children’s services commissioners and
parenting commissioners.
The CHPP will be developed through
children’s trust arrangements and will involve:
Public Service Agreement (PSA) delivery
agreements and operational plans:
• a joint strategic needs assessment,
including a meaningful engagement with
users about the services that they require;
• Guidance on Joint Strategic Needs
Assessment (DH, 2007c); and
• planning services, in particular preventive
services, based on the joint strategic needs
assessment and dialogue with potential
providers from the public, private and third
sectors;
• the development of delivery partnerships
based on contracts, grants, service level
agreements or other appropriate clear
statements of the services to be delivered;
and
• monitoring the impact of providers on the
outcomes, and refining the service based
on this information.
The CHPP is a core programme for delivering
national priorities and statutory responsibilities
on local partnerships, for example to promote
the five Every Child Matters outcomes
through children’s trust arrangements and
to reduce inequalities in outcomes for young
children. It forms the basis for ensuring that
national priorities are met, as set out in the
2008/09 Operating Framework (DH, 2007d),
• Joint Planning and Commissioning
Framework for Children, Young People and
Maternity Services (DfES and DH, 2006).
The NHS operating framework
The national NHS priority for 2008/09 is:
‘keeping adults and children well, improving
their health and reducing health inequalities’
(DH, 2007d). One of the four areas where
primary care trusts (PCTs) are expected to
make progress and where the CHPP has
an important contribution to make is in
‘improving children’s and young people’s
physical and mental health and wellbeing’.
National priorities for local delivery
The CHPP supports the delivery of:
• an increase in the percentage of women
who have seen a midwife or a maternity
healthcare professional, for assessment
of health and social care needs, risks
and choices by 12 completed weeks
of pregnancy;
63
• an increase in the percentage of infants
being breastfed at six to eight weeks;
• a reduction in the under-18 conception rate
per 1,000 females aged 15–17;
• a reduction in obesity among primary
school age children;
• an increase in the proportion of children
who complete immunisation by
recommended ages; and
• a reduction in smoking prevalence among
people aged 16 or over and in routine and
manual groups.
PSA delivery agreements
This updated CHPP has been designed
to support delivery of a range of crossgovernment PSA indicators:
• PSA Delivery Agreement 18 – Promote
better health for all: Indicator 3, Smoking
prevalence.
• PSA Delivery Agreement 14 – Increase the
number of children and young people on
the path to success: Indicator 4, Reduce
the under-18 conception rate.
Joint strategic needs assessment:
assessing the needs of children and
young people
• PSA Delivery Agreement 12 – Improve
the health and wellbeing of children and
young people: Indicator 1, Prevalence of
breast feeding at six to eight weeks; and
Indicator 3, Levels of obesity in children
under 11 years.
Joint strategic needs assessment is a process
for identifying the current and future health
and wellbeing needs of a local population,
informing the priorities and targets set by
local area agreements, and leading to agreed
commissioning priorities that will improve
outcomes and reduce health inequalities.
• PSA Delivery Agreement 13 – Improve
children and young people’s safety:
Indicator 3, Hospital admissions caused
by unintentional and deliberate injuries to
children and young people.
The CHPP (according to DH, 2007c) both
informs, and is informed by, joint strategic
needs assessment:
• PSA Delivery Agreement 19 – Ensure better
care for all: Indicator 4, The percentage
of women who have seen a midwife or
a maternity healthcare professional, for
health and social care assessment of needs,
risks and choices by 12 completed weeks
of pregnancy.
• PSA Delivery Agreement 10 – Raise the
educational achievement of all children
and young people: Indicator 1, Early Years
Foundation Stage achievement.
64
• PSA Delivery Agreement 11 – Narrow
the gap in educational achievement
between children from low-income and
disadvantaged backgrounds and their
peers: Indicator 1, Achievement gap at
Early Years Foundation Stage.
‘The Children Act 2004 requires local
authorities to prepare and publish an
overarching plan setting out their strategy
for discharging their functions in relation to
children and young people. The Children
and Young People’s Plan (CYPP) is prepared
by local authorities and their partners
through the local children’s trust cooperation
arrangements, feeding into and informed by
the Sustainable Communities Strategy. A key
element of the CYPP is the requirement to
carry out a comprehensive needs assessment,
in partnership with all those involved in the
The CHPP as set out in this publication
fits well with commissioners wanting to
demonstrate world-class commissioning, as it
reflects many key competences. The CHPP is:
• strategic – taking an overview of children’s
and families’ health and wellbeing;
• long-term – improving future outcomes
for children and families through early
intervention and prevention;
planning process, and to review it on a regular
basis. The needs assessment is based on the
requirement to improve the five Every Child
Matters outcomes for children, young people
and their families: be healthy, stay safe, enjoy
and achieve, make a positive contribution,
and achieve economic wellbeing.’
World-class commissioning: adding
life to years and years to life
World Class Commissioning (DH, 2007e)
sets out a new approach for health and care
services. It is the underpinning delivery vehicle
for many objectives of current health policy,
and presents the vision and competences for
world-class commissioning. PCTs will lead the
work to turn the world-class commissioning
vision into reality, applying it locally in a
way that meets the needs and priorities of
the local population.
• outcome-driven – providing a clear set
of outcomes for children that can be
measured;
• evidence-based – it is based on meta-level
reviews of evidence, including Health for
All Children (Hall and Elliman, 2006),
National Institute for Health and Clinical
Excellence guidance, and a review of
evidence-based, health-led parenting
interventions;
• partnership-focused – the CHPP can only
be delivered through joint commissioning
of children’s services in partnership with
families and communities; and
• clinically led and highly professional –
successful commissioning of the CHPP
requires high levels of engagement by
health professionals.
65
Annex B:
Core elements of the
CHPP workforce
Introduction
Successful delivery of the CHPP will depend
on having the right workforce in place to
deliver the programme. Significant changes
are taking place in the children’s workforce
that are impacting on the provision of
the CHPP. In producing this guide, we
commissioned a review of national workforce
developments impacting on the CHPP
workforce and an analysis of the competences
required to deliver the programme. This annex
has been included to assist commissioners
and local managers to ensure that they have
the workforce needed to deliver the CHPP
standard described in this guide.
The CHPP workforce
Delivery of the programme relies on a team
approach that includes children’s centre staff
and members of the primary healthcare
team. An effective, competent and confident
workforce, capable of delivering the CHPP
during pregnancy and the first years of life,
will have the following characteristics:
• multi-skilled teamworking involving a range
of practitioners across general practice,
maternity services and children’s centre
services;
66
• an agreed and defined lead role for the
health visitor;
• a team with up-to-date knowledge and
skills; and
• a team with competences to work in
partnership with children, mothers, fathers
and families to deliver the core elements
of the CHPP and to work effectively across
service boundaries.
Multi-skilled teamworking
Delivering the CHPP relies on the contribution
of a broad spectrum of practitioners,
including GPs, practice nurses, midwives,
health visitors, community nursery nurses,
early years practitioners, family support
workers and other practitioners employed by
children’s centres or working for voluntary
organisations.
The primary care trust (PCT) will work
within local children’s trust arrangements in
commissioning children’s services. This should
include accurate assessment of need and
proportionate allocation of resources to deliver
the CHPP, and work with partners to ensure
that this service is integrated with wider
provision, including children’s centres.
The key to success is a shared understanding
– both by parents and by all the practitioners
involved – of the roles, responsibilities
and potential contribution of the different
practitioners and organisations.
The GP and primary care team provide child
health surveillance, health protection and
clinical care.
Sure Start children’s centres and the CHPP
share similar objectives. Just as children’s
centres rely on the contribution of health
services, the health team relies on early years
staff to provide proactive health-promoting
interventions, as well as to assist in the
provision of a range of targeted support for
families in need. Children’s centre teams have
expertise in the delivery of high-quality early
years provision and parenting support.
Teamworking can benefit from, but does
not depend on, co-location. What matters
is that people meet regularly to review the
programme and discuss individual children.
Teamworking across service boundaries
requires practitioners to:
• develop trusting relationships, based on
a shared purpose, values and language;
• know when and how to share information
appropriately;
• make use of common processes, such as
the Common Assessment Framework; and
• nominate a lead professional to co-ordinate
activity.
Clear lines of accountability and responsibility
must be defined, when practitioners from
different organisations work together in
integrated teams.
An agreed and defined lead role for
the health visitor
The CHPP is a clinical and public health
programme led by, and dependent on, health
professionals. Effective leadership is required
to ensure that the various practitioners
contributing to the CHPP communicate
with each other and provide an holistic,
co-ordinated service tailored to local needs.
It is recommended that responsibility for
co-ordinating the CHPP to a defined
population at children’s centre and general
practice level should rest with the health
visitor. Having a public health nursing
background, health visitors are ideally placed;
they have a registered population of children
from pregnancy to five years, they know
how the health system works, and they
bring knowledge and understanding of child
and family health and wellbeing and skills in
working with individuals and communities.
They will need to work across general practice
and children’s centres, working closely
with maternity services and other agencies
concerned with children and families
This role is hands-on, working with children
and families, overseeing and delivering the
CHPP to a defined and registered population,
involving local parents, co-ordinating and
supporting the contribution of the team,
quality-assuring the service and monitoring
the outcomes and delivery of the programme.
A pilot project is currently working with 10
sites to test this role and explore the training
and support needs of health visitors to lead
the CHPP.
67
The leadership model is one of distributed
responsibility, whereby everybody has an
equally important role to play in delivering
the component parts of the CHPP. GPs and
children’s centre managers will have a key
role in maximising the contribution made
by their services.
Health professionals, such as midwives, health
visitors and GPs, are the universal first point of
contact for families during pregnancy and the
first years of life. They have credibility when
it comes to diagnosis, health information,
guidance and decision making. Health
professionals are trained and experienced in
working with both adults and children, and
are able to work with the whole family. They
are ideally placed to identify and provide
support for problems as soon as they arise,
drawing in, where necessary, support from
other services. Midwives have an important
role in promoting the health of the child and
the family.
Every registered health profession has a
code of professional conduct, and an agreed
body of knowledge, defined by specified
competences and assessment frameworks.
This provides assurance to the public of the
standard of care they can expect.
A team with up-to-date knowledge
and skills
This updated CHPP identifies new priorities
and advances in our understanding of child
development and effective interventions.
The knowledge and skills of the team
delivering the CHPP will need to reflect these
changes and be open and flexible to future
developments. In addition to existing public
health and child development knowledge and
68
skills, topics identified in this guide for greater
focus are:
• the early identification and prevention
of obesity;
• the promotion and support of
breastfeeding;
• the impact of the early nurturing
environment on the developing brain and
interventions to promote optimal physical,
social and emotional development;
• the important contribution of fathers;
• factors influencing health choices and
behaviour change;
• parenting support using strength-based
and promotional intervening skills and
tools; and
• high-level skills to deliver an intensive
programme to at-risk families in the home.
A team with the competences to work
with children and parents, to deliver
the core elements of the CHPP and
to work effectively across service
boundaries
Competences are the knowledge, skills,
behaviour and characteristics required to carry
out an activity (or combination of activities)
in a particular environment or organisational
context, in a way that leads to effective and
enhanced organisational performance. It is
necessary to stipulate both the range and level
of competences required across the available
workforce, as well as the specific competences
required to undertake specialist tasks.
There are some higher-level competences
that are health professional-specific (such as
the clinical skill of listening for heart murmurs
in six-week-old babies). This means that,
while there is opportunity for flexibility in the
workforce profile, some tasks and skills are
non-transferable.
With so many practitioners potentially
involved in supporting children and families,
it is essential that everybody is aware of
their own areas of responsibility and those of
others, how they interact and overlap with
other roles, the skills and knowledge they
require to do the job, and the limits to their
competence.
Enhanced levels of competence are required
where additional skills are needed to explore
sensitive issues or establish and respond to
varying levels of vulnerability, complexity
and risk.
In addition to identifying and specifying skills
and competences, arrangements need to be in
place for appropriate training and continuing
development, including joint cross-discipline
training, particularly where new roles emerge
or roles overlap. There should also be the
opportunity for those skills to be recognised
and accredited, to avoid duplication, improve
joint working and support workforce and
cross-sector mobility.
A competent, confident and effective
practitioner is more than the sum of his or
her competences; sensitive and appropriate
decision making is often underpinned by
professional insight grounded in a wealth
of experience. A less-skilled practitioner
can undertake aspects of care under the
supervision and guidance of a more competent
practitioner. However, investing in professionals
with higher-level competences can be more
cost-effective in terms of outcomes.
Support workers should be trained to the
appropriate level of skill and competency for
their role and should not work outside their
job specification.
Practitioners working in multi-agency settings
need the ability to work effectively across
traditional service boundaries and to share
information, as well as specific knowledge of
what services are available locally and how
to access them, including use of shared tools
such as the Common Assessment Framework
and lead professional role.
Besides the competences required to deliver
the specific components of the CHPP,
additional competences are required to
lead a multidisciplinary team designing and
delivering needs-based, outcomes-driven
interventions across a range of settings.
69
Competences required for the delivery
of the CHPP
• Allpractitionerswhoworkwith
children, young people and families
should be able to demonstrate a
basic level of competence in the six
areas of The Common Core of Skills
and Knowledge for the Children’s
Workforce (DfES, 2005b).
The health-visiting workforce is central to the
delivery of the CHPP. This was recognised
in the review of the future role of the health
visitor, Facing the Future (DH, 2007b), which
recommended that health visitors should
focus on young children and families, where
their public health nursing expertise can have
greatest impact.
• Ideally,promotinghealthshould
be added to the Common Core of
Skills and Knowledge as an essential
prerequisite for all those working with
children.
The review identified the core elements of
health visiting as:
• Ofparticularrelevancefor
practitioners working with families
with young children is the capacity
to build effective and sensitive
relationships with the parents: all
practitioners working with this client
group are therefore expected to
demonstrate compliance with the
National Occupational Standards for
Work with Parents (Lifelong Learning
UK, 2005).
• prevention and early intervention;
• Competencesrequiredforthe
delivery of specific aspects of the
CHPP should be explicit in the job
specifications of relevant practitioners.
These competences should relate to
the achievement of health outcomes
identified during the joint strategic
health needs assessment and specified
in The Children and Young People’s
Plan (DfES, 2005a).
• Variousframeworksandtoolsexist
to help service planners to identify
the competences required for the
achievement of specific outcomes.
70
The role of the health visitor
• public health nursing;
• working with the whole family;
• knowing the community and ‘being local’;
• being proactive in promoting health and
preventing ill health;
• progressive universalism;
• safeguarding children;
• working across organisational boundaries;
• teamwork and partnership;
• readiness to provide a health protection
service; and
• home visiting.
The review concluded that there were two
core roles for health visitors:
• leading the delivery of the CHPP to a
defined population; and
• delivering intensive preventive programmes
to the most at-risk families with young
children.
Local workforce planning for the CHPP will
need to ensure that the health visitor has a
lead role in the CHPP and has the skills and
knowledge needed to lead and deliver the
programme as described in this publication.
Possible roles in the CHPP team
The health visitor. The CHPP team is often
a virtual team across a number of settings
and organisations, requiring leadership skills
to ensure that the universal and progressive
needs of families and children are met. The
CHPP health visitor will have a key role in
ensuring that there are robust arrangements
for identifying where families need extra
support, assessing needs and co-ordinating
multi-agency activity.
The GP and practice nurse are a core part of
the CHPP team. Most children are seen by
a GP up to six times a year in the first years
of life. General practice has an important
role to play in delivering the CHPP, through
screening, surveillance and immunisations, as
well as opportunistically promoting health.
The midwife role, in addition to assessing
health and social needs, is to ensure that all
screening tests are understood and available
to all women. They make sure that pregnancy
is monitored through to delivery of the baby.
They may maintain contact for up to 28 days
after delivery, as necessary.
Sure Start children’s centre staff – such as
family support workers, parent engagement
workers, early years practitioners, outreach
workers and play leaders – all have an
important part to play in the CHPP. Not
only do they provide many of the parenting
support and child development and childcare
services that are essential for children’s health,
but they also increasingly have a role in health
promotion and public health. As the CHPP
lead, it is expected that the health visitor will
support and supervise children’s centre staff to
acquire the competences needed to support
delivery of the CHPP.
With the growing emphasis on the importance
of behavioural change in improving the health
of the nation, and the need to spread the
message more widely and engage with hardto-reach families, health trainers may also
provide a useful addition to the team.
Administrative assistance is vital to ensure
cost-effective use of the team. Administrative
support is needed to facilitate engagement
with families, to provide and collect
information, and to monitor and review
the CHPP.
Community nursery nurses have proved an
invaluable asset to health-visiting teams.
Community staff nurses have a particular role
to play in supporting children and families
with healthcare needs.
71
Effective teamworking for the CHPP
• Clearinformationforfamiliesabout
the roles and responsibilities of each
practitioner with whom they come into
contact should be provided.
• Theremustbeacoreteam,ledby
a health professional responsible for
ensuring that all families receive a level
of service and support relevant to their
needs.
• Theremustbecleararrangementsfor
engaging and drawing in support from
services outside the core team.
• RegularmeetingstodiscusstheCHPP
and individual children should be held.
• Decisionsaboutwhatsortof
practitioners are needed should be based
on the competences required to deliver
desired outcomes.
• Theremustbeacleardescriptionofthe
performance standards required within
any particular role, and everybody
Education and learning
Competences relating to maternal and
child health should be underpinned by a
knowledge of relevant legislation relating to
confidentiality, consent, record keeping and
information sharing; children’s rights; key
government policies; relevant guidance; main
issues and debates (relating to child and family
health); factors affecting health and parenting
capacity; the evidence base for practice; the
art of communication; and an awareness of
one’s own sphere of competence and the roles
of other practitioners.
should have access to regular supervision
and an annual opportunity to review
their sphere of practice and training
needs.
• Theremustbeclearlinesof
accountability and responsibility,
especially when these transcend
traditional organisational boundaries.
• Thereshouldberegularopportunities
for communication across teams, to
generate trust and understanding.
• Wheneverpossible,trainingshouldbe
designed for a multidisciplinary audience
and should be of a high standard, with
clear learning outcomes that can be
assessed following attendance.
• Sharedbudgetsandjointplanning
lead to co-ordinated service provision
that makes best use of the available
workforce and avoids duplication,
confusion and the tendency to retreat
into professional ‘silos’.
The Children’s Workforce Development
Council94 is involved in a pilot project to
develop induction standards for the children’s
workforce. The standards cover seven core
areas:
• the principles and values essential for
working with children and young people;
• the worker’s role;
• health and safety requirements;
• effective communication;
• development of children and young people;
• keeping children safe from harm; and
• personal and professional development.
94 www.cwdcouncil.org.uk
72
It is hoped that PCTs and local authorities will
incorporate shared induction programmes to
promote integrated early years provision.
Developing competence requires access to
courses that are recognised, standardised,
assessed and credible. Local authorities
are responsible for delivering training to
practitioners across the local area in the
Common Assessment Framework, in
the use of the lead professional and in
information sharing.
Maintaining competence requires regular
opportunities to apply knowledge, share
experience, practise skills, review competence
and identify training needs. Service managers
should ensure that individual and service
training needs are reviewed on an annual
basis and that appropriate opportunities for
developing knowledge and skills are provided.
The use of competence assessment tools,
such as the Coventry University Assessment,95
should be encouraged, so that knowledge and
skills deficits can be identified and addressed.
Multidisciplinary training opportunities should
be encouraged, to avoid conflicting advice,
share perspectives, boost confidence and
deliver more integrated, tailored support to
service users.
Opportunities for self-study should also be
explored. For example, an online training
programme is currently under development as
part of the HENRY (Health, Exercise, Nutrition
for the Really Young) programme, led by
Dr Mary Rudolf.96
95 www.healthbehaviourresearch.co.uk
96 For information, email [email protected]
73
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